- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.64 / $3.64 / $3.64
| Facility | | $3.64 | $3.64 | $3.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.15 / $2.84 / $2,362.50
| Professional | | $2.15 | $2.84 | $2,362.50 |
- 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
- $2.80 / $2.80 / $2.80
| Professional | | $2.80 | $2.80 | $2.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.27 / $2.48 / $2.90
| Professional | | $2.27 | $2.48 | $2.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.06 / $2.06 / $3.11
| Professional | | $2.06 | $2.06 | $3.11 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.36 / $1.99 / $2.48
| Professional | | $1.36 | $1.99 | $2.48 |