- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.36 / $4.36 / $4.36
| Facility | | $4.36 | $4.36 | $4.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.87 / $1.87 / $1.87
| Professional | | $1.87 | $1.87 | $1.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.37 / $4.37 / $4.37
| Facility | | $4.37 | $4.37 | $4.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.85 / $1.85 / $1.85
| Professional | | $1.85 | $1.85 | $1.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.76 / $2.76 / $2.76
| Professional | | $2.76 | $2.76 | $2.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.02 / $2.22 / $2.59
| Professional | | $2.02 | $2.22 | $2.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.85 / $2.27 / $2.78
| Professional | | $1.85 | $2.27 | $2.78 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.00 / $2.59 / $3.80
| Professional | | $2.00 | $2.59 | $3.80 |