- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.84 / $2.84 / $2.84
| Facility | | $2.84 | $2.84 | $2.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.22 / $1.22 / $1.93
| Professional | | $1.22 | $1.22 | $1.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.83 / $2.83 / $2.83
| Facility | | $2.83 | $2.83 | $2.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.22 / $1.22 / $2.80
| Professional | | $1.22 | $1.22 | $2.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.40 / $3.40 / $3.40
| Professional | | $3.40 | $3.40 | $3.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.22 / $1.46 / $1.83
| Professional | | $1.22 | $1.46 | $1.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.22 / $1.29 / $2.80
| Professional | | $1.22 | $1.29 | $2.80 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.59 / $2.04 / $33.40
| Professional | | $1.59 | $2.04 | $33.40 |