- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.88 / $3.73 / $7.90
| Professional | | $1.88 | $3.73 | $7.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.78 / $3.78 / $3.78
| Facility | | $3.78 | $3.78 | $3.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.81 / $1.81 / $1.81
| Professional | | $1.81 | $1.81 | $1.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.63 / $2.63 / $2.63
| Professional | | $2.63 | $2.63 | $2.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.99 / $2.17 / $2.52
| Professional | | $1.99 | $2.17 | $2.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.81 / $2.16 / $2.72
| Professional | | $1.81 | $2.16 | $2.72 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.28 / $2.19 / $3.31
| Professional | | $1.28 | $2.19 | $3.31 |