- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.76 / $22.77 / $22.77
| Facility | | $5.76 | $22.77 | $22.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.89 / $2.49 / $6.63
| Professional | | $1.89 | $2.49 | $6.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.77 / $5.77 / $5.77
| Facility | | $5.77 | $5.77 | $5.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.82 / $1.82 / $1.82
| Professional | | $1.82 | $1.82 | $1.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.57 / $2.57 / $2.57
| Professional | | $2.57 | $2.57 | $2.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.00 / $2.18 / $2.54
| Professional | | $2.00 | $2.18 | $2.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.82 / $2.12 / $2.73
| Professional | | $1.82 | $2.12 | $2.73 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.79 / $2.98 / $3.73
| Professional | | $1.79 | $2.98 | $3.73 |