- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.08 / $4.63 / $5.94
| Facility | | $4.08 | $4.63 | $5.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.94 / $5.94 / $5.94
| Professional | | $5.94 | $5.94 | $5.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.06 / $8.55 / $10.09
| Professional | | $8.06 | $8.55 | $10.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.95 / $5.94 / $7.43
| Professional | | $4.95 | $5.94 | $7.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.08 / $5.94 / $7.43
| Professional | | $2.08 | $5.94 | $7.43 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.95 / $4.95 / $5.54
| Professional | | $4.95 | $4.95 | $5.54 |