- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.36 / $2.36 / $2.36
| Professional | | $2.36 | $2.36 | $2.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.05 / $4.05 / $4.05
| Facility | | $4.05 | $4.05 | $4.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.53 / $3.53 / $5.61
| Professional | | $3.53 | $3.53 | $5.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.09 / $5.34 / $5.34
| Professional | | $5.09 | $5.34 | $5.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.57 / $5.09 / $7.14
| Professional | | $3.57 | $5.09 | $7.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.43 / $4.05 / $5.61
| Professional | | $3.43 | $4.05 | $5.61 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.48 / $4.24 / $4.84
| Professional | | $3.48 | $4.24 | $4.84 |