- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.14 / $3.14 / $3.14
| Facility | | $3.14 | $3.14 | $3.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.13 / $3.13 / $3.13
| Facility | | $3.13 | $3.13 | $3.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.70 / $1.70 / $1.70
| Professional | | $1.70 | $1.70 | $1.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.87 / $2.04 / $2.38
| Professional | | $1.87 | $2.04 | $2.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.70 / $1.99 / $2.54
| Professional | | $1.70 | $1.99 | $2.54 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.95 / $1.70 / $2.14
| Professional | | $0.95 | $1.70 | $2.14 |