- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.18 / $2.18 / $2.18
| Professional | | $2.18 | $2.18 | $2.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.69 / $2.69 / $2.69
| Facility | | $2.69 | $2.69 | $2.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.02 / $3.06 / $3.73
| Professional | | $3.02 | $3.06 | $3.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.39 / $3.55 / $3.55
| Professional | | $3.39 | $3.55 | $3.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.02 / $3.39 / $4.75
| Professional | | $2.02 | $3.39 | $4.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.29 / $3.17 / $3.73
| Professional | | $2.29 | $3.17 | $3.73 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.29 / $2.83 / $3.23
| Professional | | $2.29 | $2.83 | $3.23 |