- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.23 / $4.26 / $10.00
| Professional | | $3.23 | $4.26 | $10.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7.57 / $7.57 / $7.57
| Facility | | $7.57 | $7.57 | $7.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.11 / $3.11 / $3.11
| Professional | | $3.11 | $3.11 | $3.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.26 / $5.26 / $5.26
| Professional | | $5.26 | $5.26 | $5.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.42 / $3.74 / $4.36
| Professional | | $3.42 | $3.74 | $4.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.11 / $4.32 / $4.67
| Professional | | $3.11 | $4.32 | $4.67 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.52 / $4.36 / $6.44
| Professional | | $2.52 | $4.36 | $6.44 |