- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.78 / $2.78 / $2.78
| Facility | | $2.78 | $2.78 | $2.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.88 / $0.88 / $1.64
| Professional | | $0.88 | $0.88 | $1.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.77 / $2.77 / $2.77
| Facility | | $2.77 | $2.77 | $2.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.88 / $0.88 / $1.86
| Professional | | $0.88 | $0.88 | $1.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.06 / $2.06 / $2.06
| Professional | | $2.06 | $2.06 | $2.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.88 / $1.06 / $1.32
| Professional | | $0.88 | $1.06 | $1.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.88 / $0.93 / $1.70
| Professional | | $0.88 | $0.93 | $1.70 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.44 / $1.83 / $39.25
| Professional | | $1.44 | $1.83 | $39.25 |