- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6.24 / $26.77 / $26.77
| Facility | | $6.24 | $26.77 | $26.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.82 / $2.82 / $2.82
| Professional | | $2.82 | $2.82 | $2.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6.23 / $6.23 / $6.23
| Facility | | $6.23 | $6.23 | $6.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.04 / $2.04 / $2.04
| Professional | | $2.04 | $2.04 | $2.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.11 / $3.11 / $3.11
| Professional | | $3.11 | $3.11 | $3.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.24 / $2.44 / $2.85
| Professional | | $2.24 | $2.44 | $2.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.04 / $2.54 / $3.06
| Professional | | $2.04 | $2.54 | $3.06 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.22 / $3.21 / $8.66
| Professional | | $2.22 | $3.21 | $8.66 |