- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.80 / $2.80 / $2.80
| Facility | | $2.80 | $2.80 | $2.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.11 / $2.11 / $2.31
| Professional | | $2.11 | $2.11 | $2.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.80 / $2.80 / $2.80
| Facility | | $2.80 | $2.80 | $2.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.56 / $2.11 / $2.11
| Professional | | $1.56 | $2.11 | $2.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.02 / $2.02 / $2.02
| Professional | | $2.02 | $2.02 | $2.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.11 / $2.52 / $3.17
| Professional | | $2.11 | $2.52 | $3.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.66 / $2.11 / $3.17
| Professional | | $1.66 | $2.11 | $3.17 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.36 / $1.67 / $2.10
| Professional | | $1.36 | $1.67 | $2.10 |