- 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
- $4.45 / $4.49 / $502.64
| Professional | | $4.45 | $4.49 | $502.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.15 / $8.15 / $8.15
| Facility | | $8.15 | $8.15 | $8.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.37 / $4.45 / $5.62
| Professional | | $4.37 | $4.45 | $5.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.33 / $5.33 / $5.33
| Professional | | $5.33 | $5.33 | $5.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.45 / $5.34 / $6.67
| Professional | | $4.45 | $5.34 | $6.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.37 / $4.72 / $6.68
| Professional | | $4.37 | $4.72 | $6.68 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.12 / $4.75 / $5.52
| Professional | | $4.12 | $4.75 | $5.52 |