- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.60 / $2.60 / $2.60
| Facility | | $2.60 | $2.60 | $2.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.55 / $1.55 / $2.04
| Professional | | $1.55 | $1.55 | $2.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.59 / $2.59 / $2.59
| Facility | | $2.59 | $2.59 | $2.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.49 / $1.49 / $1.49
| Professional | | $1.49 | $1.49 | $1.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.64 / $1.79 / $2.09
| Professional | | $1.64 | $1.79 | $2.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.49 / $1.74 / $2.24
| Professional | | $1.49 | $1.74 | $2.24 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.07 / $1.40 / $1.75
| Professional | | $1.07 | $1.40 | $1.75 |