- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.68 / $1.68 / $1.68
| Facility | | $1.68 | $1.68 | $1.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.93 / $0.95 / $26.23
| Professional | | $0.93 | $0.95 | $26.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.68 / $1.68 / $1.68
| Facility | | $1.68 | $1.68 | $1.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.94 / $0.94 / $1.38
| Professional | | $0.94 | $0.94 | $1.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.22 / $1.22 / $1.22
| Professional | | $1.22 | $1.22 | $1.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.94 / $1.12 / $1.41
| Professional | | $0.94 | $1.12 | $1.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.94 / $1.00 / $1.41
| Professional | | $0.94 | $1.00 | $1.41 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.73 / $1.11 / $1.37
| Professional | | $0.73 | $1.11 | $1.37 |