- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.69 / $3.24 / $3.98
| Facility | | $2.69 | $3.24 | $3.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.00 / $2.00 / $3.02
| Professional | | $1.00 | $2.00 | $3.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.95 / $1.95 / $3.98
| Professional | | $1.95 | $1.95 | $3.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.27 / $5.50 / $6.17
| Professional | | $4.27 | $5.50 | $6.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.31 / $3.98 / $4.90
| Professional | | $3.31 | $3.98 | $4.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.38 / $3.98 / $4.90
| Professional | | $1.38 | $3.98 | $4.90 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.63 / $4.57 / $6.46
| Professional | | $3.63 | $4.57 | $6.46 |