- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.23 / $0.23 / $0.23
| Professional | | $0.23 | $0.23 | $0.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.37 / $0.37 / $0.37
| Facility | | $0.37 | $0.37 | $0.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.32 / $0.32 / $0.50
| Professional | | $0.32 | $0.32 | $0.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.45 / $0.47 / $0.47
| Professional | | $0.45 | $0.47 | $0.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.32 / $0.45 / $0.63
| Professional | | $0.32 | $0.45 | $0.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.16 / $0.30 / $0.30
| Facility | | $0.16 | $0.30 | $0.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.28 / $0.37 / $0.50
| Professional | | $0.28 | $0.37 | $0.50 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.37 / $0.38 / $0.43
| Professional | | $0.37 | $0.38 | $0.43 |