- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.46 / $2.46 / $2.46
| Facility | | $2.46 | $2.46 | $2.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.46 / $2.46 / $2.46
| Facility | | $2.46 | $2.46 | $2.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.79 / $0.79 / $0.79
| Professional | | $0.79 | $0.79 | $0.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.56 / $1.56 / $1.56
| Professional | | $1.56 | $1.56 | $1.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.87 / $0.94 / $1.10
| Professional | | $0.87 | $0.94 | $1.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.79 / $1.19 / $1.28
| Professional | | $0.79 | $1.19 | $1.28 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.64 / $1.57 / $2.38
| Professional | | $0.64 | $1.57 | $2.38 |