- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.50 / $2.50 / $2.50
| Professional | | $2.50 | $2.50 | $2.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.03 / $4.03 / $4.03
| Facility | | $4.03 | $4.03 | $4.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.50 / $6.28 / $6.28
| Professional | | $5.50 | $6.28 | $6.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.08 / $5.32 / $5.32
| Professional | | $5.08 | $5.32 | $5.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.50 / $5.08 / $7.11
| Professional | | $3.50 | $5.08 | $7.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.63 / $4.73 / $6.32
| Professional | | $3.63 | $4.73 | $6.32 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.42 / $4.08 / $4.83
| Professional | | $2.42 | $4.08 | $4.83 |