- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.20 / $5.20 / $5.20
| Facility | | $5.20 | $5.20 | $5.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.37 / $2.46 / $8.73
| Professional | | $2.37 | $2.46 | $8.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.20 / $5.20 / $5.20
| Facility | | $5.20 | $5.20 | $5.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.37 / $2.37 / $2.37
| Professional | | $2.37 | $2.37 | $2.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.88 / $2.88 / $2.88
| Professional | | $2.88 | $2.88 | $2.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.61 / $2.85 / $3.32
| Professional | | $2.61 | $2.85 | $3.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.36 / $2.37 / $3.56
| Professional | | $2.36 | $2.37 | $3.56 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.93 / $2.72 / $4.43
| Professional | | $1.93 | $2.72 | $4.43 |