- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.93 / $0.93 / $0.93
| Professional | | $0.93 | $0.93 | $0.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.02 / $2.02 / $2.02
| Facility | | $2.02 | $2.02 | $2.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.08 / $2.08 / $2.79
| Professional | | $2.08 | $2.08 | $2.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.54 / $2.66 / $2.66
| Professional | | $2.54 | $2.66 | $2.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.59 / $2.54 / $3.56
| Professional | | $1.59 | $2.54 | $3.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.59 / $1.59 / $1.59
| Facility | | $1.59 | $1.59 | $1.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.77 / $2.02 / $2.79
| Professional | | $1.77 | $2.02 | $2.79 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.04 / $2.12 / $2.42
| Professional | | $2.04 | $2.12 | $2.42 |