- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.52 / $3.99 / $5.12
| Facility | | $3.52 | $3.99 | $5.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.12 / $5.12 / $5.12
| Professional | | $5.12 | $5.12 | $5.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.35 / $10.29 / $10.29
| Professional | | $9.35 | $10.29 | $10.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.26 / $5.12 / $6.41
| Professional | | $4.26 | $5.12 | $6.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.56 / $5.12 / $10.50
| Professional | | $2.56 | $5.12 | $10.50 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.26 / $4.26 / $4.26
| Professional | | $4.26 | $4.26 | $4.26 |