- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.05 / $1.05 / $1.05
| Professional | | $1.05 | $1.05 | $1.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.04 / $2.04 / $2.04
| Facility | | $2.04 | $2.04 | $2.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.61 / $1.61 / $2.81
| Professional | | $1.61 | $1.61 | $2.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.54 / $2.67 / $2.67
| Professional | | $2.54 | $2.67 | $2.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.79 / $2.54 / $3.57
| Professional | | $1.79 | $2.54 | $3.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.44 / $2.04 / $2.81
| Professional | | $1.44 | $2.04 | $2.81 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.75 / $2.13 / $2.43
| Professional | | $1.75 | $2.13 | $2.43 |