- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.25 / $2.25 / $2.25
| Facility | | $2.25 | $2.25 | $2.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.25 / $2.25 / $2.25
| Facility | | $2.25 | $2.25 | $2.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.09 / $1.09 / $1.09
| Professional | | $1.09 | $1.09 | $1.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.19 / $1.30 / $1.52
| Professional | | $1.19 | $1.30 | $1.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.09 / $1.34 / $1.64
| Professional | | $1.09 | $1.34 | $1.64 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.79 / $1.25 / $1.44
| Professional | | $0.79 | $1.25 | $1.44 |