- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.37 / $3.37 / $3.37
| Professional | | $3.37 | $3.37 | $3.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.14 / $3.14 / $3.14
| Facility | | $3.14 | $3.14 | $3.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.13 / $4.86 / $4.86
| Professional | | $4.13 | $4.86 | $4.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.95 / $4.13 / $4.13
| Professional | | $3.95 | $4.13 | $4.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.77 / $3.95 / $5.53
| Professional | | $2.77 | $3.95 | $5.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.14 / $4.34 / $4.86
| Professional | | $3.14 | $4.34 | $4.86 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.18 / $3.29 / $3.76
| Professional | | $3.18 | $3.29 | $3.76 |