- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.90 / $1.90 / $1.90
| Facility | | $1.90 | $1.90 | $1.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.90 / $1.90 / $1.90
| Facility | | $1.90 | $1.90 | $1.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.38 / $0.38 / $0.38
| Professional | | $0.38 | $0.38 | $0.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.80 / $0.80 / $0.80
| Professional | | $0.80 | $0.80 | $0.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.42 / $0.46 / $0.54
| Professional | | $0.42 | $0.46 | $0.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.39 / $0.59 / $0.65
| Professional | | $0.39 | $0.59 | $0.65 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.71 / $1.24 / $3.10
| Professional | | $0.71 | $1.24 | $3.10 |