- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.90 / $3.90 / $9.52
| Facility | | $3.90 | $3.90 | $9.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.01 / $2.25 / $6.63
| Professional | | $1.01 | $2.25 | $6.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.91 / $3.91 / $3.91
| Facility | | $3.91 | $3.91 | $3.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.00 / $1.00 / $1.00
| Professional | | $1.00 | $1.00 | $1.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.08 / $4.08 / $4.08
| Professional | | $4.08 | $4.08 | $4.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.11 / $1.21 / $1.41
| Professional | | $1.11 | $1.21 | $1.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.01 / $1.52 / $1.53
| Professional | | $1.01 | $1.52 | $1.53 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.67 / $1.54 / $2.65
| Professional | | $0.67 | $1.54 | $2.65 |