- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6.38 / $6.38 / $11.30
| Facility | | $6.38 | $6.38 | $11.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.95 / $2.97 / $4.51
| Professional | | $2.95 | $2.97 | $4.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.87 / $5.87 / $5.87
| Facility | | $5.87 | $5.87 | $5.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.95 / $2.95 / $2.95
| Professional | | $2.95 | $2.95 | $2.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.21 / $5.21 / $5.21
| Professional | | $5.21 | $5.21 | $5.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.25 / $3.54 / $4.13
| Professional | | $3.25 | $3.54 | $4.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.28 / $4.28 / $4.43
| Professional | | $3.28 | $4.28 | $4.43 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.25 / $3.09 / $4.34
| Professional | | $2.25 | $3.09 | $4.34 |