- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.62 / $1.62 / $1.62
| Facility | | $1.62 | $1.62 | $1.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.83 / $1.83 / $2.41
| Professional | | $1.83 | $1.83 | $2.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.62 / $1.62 / $1.62
| Facility | | $1.62 | $1.62 | $1.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.76 / $1.76 / $1.93
| Professional | | $1.76 | $1.76 | $1.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.35 / $2.35 / $2.35
| Professional | | $2.35 | $2.35 | $2.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.76 / $2.11 / $2.46
| Professional | | $1.76 | $2.11 | $2.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.76 / $1.93 / $2.64
| Professional | | $1.76 | $1.93 | $2.64 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.59 / $0.86 / $1.95
| Professional | | $0.59 | $0.86 | $1.95 |