- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.40 / $4.40 / $4.40
| Facility | | $4.40 | $4.40 | $4.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.40 / $4.40 / $4.40
| Facility | | $4.40 | $4.40 | $4.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.41 / $2.41 / $2.41
| Professional | | $2.41 | $2.41 | $2.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.65 / $2.90 / $3.38
| Professional | | $2.65 | $2.90 | $3.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.41 / $2.84 / $3.62
| Professional | | $2.41 | $2.84 | $3.62 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.45 / $2.40 / $3.04
| Professional | | $1.45 | $2.40 | $3.04 |