- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.90 / $3.90 / $3.90
| Facility | | $3.90 | $3.90 | $3.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.02 / $2.10 / $34.21
| Professional | | $2.02 | $2.10 | $34.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.89 / $3.89 / $3.89
| Facility | | $3.89 | $3.89 | $3.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.02 / $2.02 / $2.02
| Professional | | $2.02 | $2.02 | $2.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.91 / $2.91 / $2.91
| Professional | | $2.91 | $2.91 | $2.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.23 / $2.43 / $2.83
| Professional | | $2.23 | $2.43 | $2.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.02 / $2.39 / $3.03
| Professional | | $2.02 | $2.39 | $3.03 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.86 / $2.41 / $3.32
| Professional | | $1.86 | $2.41 | $3.32 |