- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.49 / $2.49 / $2.49
| Professional | | $2.49 | $2.49 | $2.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.00 / $4.00 / $4.00
| Facility | | $4.00 | $4.00 | $4.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.60 / $3.60 / $5.52
| Professional | | $3.60 | $3.60 | $5.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.01 / $5.26 / $5.26
| Professional | | $5.01 | $5.26 | $5.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.51 / $5.01 / $7.03
| Professional | | $3.51 | $5.01 | $7.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.10 / $4.97 / $5.52
| Professional | | $3.10 | $4.97 | $5.52 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.52 / $4.05 / $4.78
| Professional | | $2.52 | $4.05 | $4.78 |