- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.77 / $1.77 / $1.77
| Professional | | $1.77 | $1.77 | $1.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.13 / $5.13 / $5.13
| Facility | | $5.13 | $5.13 | $5.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.59 / $4.59 / $7.11
| Professional | | $4.59 | $4.59 | $7.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.46 / $6.76 / $6.76
| Professional | | $6.46 | $6.76 | $6.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.88 / $6.46 / $9.03
| Professional | | $3.88 | $6.46 | $9.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.94 / $5.13 / $7.11
| Professional | | $3.94 | $5.13 | $7.11 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.40 / $5.39 / $6.15
| Professional | | $4.40 | $5.39 | $6.15 |