- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.44 / $2.44 / $2.44
| Facility | | $2.44 | $2.44 | $2.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.43 / $2.43 / $2.43
| Facility | | $2.43 | $2.43 | $2.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.72 / $0.72 / $0.72
| Professional | | $0.72 | $0.72 | $0.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.98 / $0.98 / $1.15
| Professional | | $0.98 | $0.98 | $1.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.80 / $0.87 / $1.01
| Professional | | $0.80 | $0.87 | $1.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.72 / $0.81 / $1.08
| Professional | | $0.72 | $0.81 | $1.08 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.81 / $1.29 / $4.67
| Professional | | $0.81 | $1.29 | $4.67 |