- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7.00 / $7.00 / $7.00
| Facility | | $7.00 | $7.00 | $7.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7.00 / $7.00 / $7.00
| Facility | | $7.00 | $7.00 | $7.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.09 / $4.09 / $4.09
| Professional | | $4.09 | $4.09 | $4.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.78 / $5.78 / $5.78
| Professional | | $5.78 | $5.78 | $5.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.51 / $4.92 / $5.75
| Professional | | $4.51 | $4.92 | $5.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.09 / $4.75 / $6.15
| Professional | | $4.09 | $4.75 | $6.15 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.78 / $3.96 / $5.11
| Professional | | $2.78 | $3.96 | $5.11 |