- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.70 / $2.70 / $2.70
| Facility | | $2.70 | $2.70 | $2.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.42 / $1.42 / $1.42
| Professional | | $1.42 | $1.42 | $1.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.97 / $1.97 / $1.97
| Professional | | $1.97 | $1.97 | $1.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.56 / $1.71 / $1.99
| Professional | | $1.56 | $1.71 | $1.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.58 / $1.62 / $2.13
| Professional | | $1.58 | $1.62 | $2.13 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.48 / $1.74 / $2.41
| Professional | | $1.48 | $1.74 | $2.41 |