- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.87 / $1.87 / $1.87
| Professional | | $1.87 | $1.87 | $1.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.03 / $3.03 / $3.03
| Facility | | $3.03 | $3.03 | $3.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.69 / $2.69 / $4.19
| Professional | | $2.69 | $2.69 | $4.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.81 / $3.99 / $3.99
| Professional | | $3.81 | $3.99 | $3.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.67 / $3.81 / $5.33
| Professional | | $2.67 | $3.81 | $5.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.31 / $3.03 / $4.19
| Professional | | $2.31 | $3.03 | $4.19 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.07 / $3.18 / $3.63
| Professional | | $3.07 | $3.18 | $3.63 |