- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.19 / $1.19 / $1.19
| Professional | | $1.19 | $1.19 | $1.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.38 / $2.38 / $2.38
| Facility | | $2.38 | $2.38 | $2.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.36 / $1.66 / $3.31
| Professional | | $1.36 | $1.66 | $3.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.01 / $3.15 / $3.15
| Professional | | $3.01 | $3.15 | $3.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.11 / $3.01 / $4.21
| Professional | | $2.11 | $3.01 | $4.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.48 / $2.38 / $3.31
| Professional | | $1.48 | $2.38 | $3.31 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.04 / $2.50 / $2.87
| Professional | | $2.04 | $2.50 | $2.87 |