- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.22 / $1.22 / $1.22
| Professional | | $1.22 | $1.22 | $1.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.00 / $2.00 / $2.00
| Facility | | $2.00 | $2.00 | $2.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.78 / $1.78 / $2.76
| Professional | | $1.78 | $1.78 | $2.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.50 / $2.63 / $2.63
| Professional | | $2.50 | $2.63 | $2.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.76 / $2.50 / $3.51
| Professional | | $1.76 | $2.50 | $3.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.25 / $2.00 / $2.76
| Professional | | $1.25 | $2.00 | $2.76 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.27 / $2.09 / $2.39
| Professional | | $1.27 | $2.09 | $2.39 |