- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.70 / $5.70 / $5.70
| Facility | | $5.70 | $5.70 | $5.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.25 / $3.29 / $7.31
| Professional | | $3.25 | $3.29 | $7.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.26 / $3.26 / $3.60
| Professional | | $3.26 | $3.26 | $3.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.74 / $3.74 / $3.74
| Professional | | $3.74 | $3.74 | $3.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.26 / $3.91 / $4.88
| Professional | | $3.26 | $3.91 | $4.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.10 / $3.31 / $4.88
| Professional | | $3.10 | $3.31 | $4.88 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.86 / $3.40 / $3.69
| Professional | | $2.86 | $3.40 | $3.69 |