- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.97 / $0.97 / $0.97
| Professional | | $0.97 | $0.97 | $0.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.62 / $1.62 / $1.62
| Facility | | $1.62 | $1.62 | $1.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.38 / $2.25 / $2.25
| Professional | | $1.38 | $2.25 | $2.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.04 / $2.15 / $2.15
| Professional | | $2.04 | $2.15 | $2.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.44 / $2.04 / $2.87
| Professional | | $1.44 | $2.04 | $2.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.14 / $1.62 / $2.54
| Professional | | $1.14 | $1.62 | $2.54 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.39 / $1.70 / $1.95
| Professional | | $1.39 | $1.70 | $1.95 |