- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.24 / $5.24 / $5.24
| Facility | | $5.24 | $5.24 | $5.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.82 / $2.84 / $3.87
| Professional | | $2.82 | $2.84 | $3.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.24 / $5.24 / $5.24
| Facility | | $5.24 | $5.24 | $5.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.52 / $2.82 / $4.05
| Professional | | $2.52 | $2.82 | $4.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.20 / $4.20 / $4.20
| Professional | | $4.20 | $4.20 | $4.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.82 / $3.38 / $4.22
| Professional | | $2.82 | $3.38 | $4.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.82 / $2.99 / $4.23
| Professional | | $2.82 | $2.99 | $4.23 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.79 / $2.74 / $4.34
| Professional | | $1.79 | $2.74 | $4.34 |