- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.80 / $5.45 / $7.00
| Facility | | $4.80 | $5.45 | $7.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.11 / $6.41 / $12.82
| Professional | | $5.11 | $6.41 | $12.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.00 / $7.00 / $7.00
| Professional | | $7.00 | $7.00 | $7.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.35 / $8.09 / $8.09
| Professional | | $7.35 | $8.09 | $8.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.83 / $7.00 / $8.75
| Professional | | $5.83 | $7.00 | $8.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.50 / $7.00 / $8.75
| Professional | | $3.50 | $7.00 | $8.75 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.08 / $5.83 / $7.29
| Professional | | $4.08 | $5.83 | $7.29 |