- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.95 / $0.95 / $0.95
| Professional | | $0.95 | $0.95 | $0.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.44 / $4.44 / $4.44
| Facility | | $4.44 | $4.44 | $4.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.53 / $1.53 / $6.15
| Professional | | $1.53 | $1.53 | $6.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.59 / $5.85 / $5.85
| Professional | | $5.59 | $5.85 | $5.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.91 / $5.59 / $7.83
| Professional | | $3.91 | $5.59 | $7.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.28 / $4.44 / $6.15
| Professional | | $1.28 | $4.44 | $6.15 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.82 / $4.65 / $5.32
| Professional | | $3.82 | $4.65 | $5.32 |