- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.50 / $1.50 / $1.50
| Professional | | $1.50 | $1.50 | $1.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.42 / $3.42 / $3.42
| Facility | | $3.42 | $3.42 | $3.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.18 / $4.74 / $4.74
| Professional | | $2.18 | $4.74 | $4.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.30 / $4.51 / $4.51
| Professional | | $4.30 | $4.51 | $4.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.94 / $4.30 / $6.03
| Professional | | $2.94 | $4.30 | $6.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.87 / $4.26 / $4.74
| Professional | | $1.87 | $4.26 | $4.74 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.47 / $3.59 / $4.09
| Professional | | $3.47 | $3.59 | $4.09 |