- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.16 / $8.16 / $8.16
| Facility | | $8.16 | $8.16 | $8.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.45 / $3.45 / $4.73
| Professional | | $3.45 | $3.45 | $4.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.16 / $8.16 / $8.16
| Facility | | $8.16 | $8.16 | $8.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.45 / $3.45 / $5.81
| Professional | | $3.45 | $3.45 | $5.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.19 / $5.19 / $5.19
| Professional | | $5.19 | $5.19 | $5.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.45 / $4.13 / $5.17
| Professional | | $3.45 | $4.13 | $5.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.45 / $3.76 / $5.18
| Professional | | $3.45 | $3.76 | $5.18 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.60 / $4.51 / $5.47
| Professional | | $3.60 | $4.51 | $5.47 |