- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.51 / $1.51 / $1.51
| Professional | | $1.51 | $1.51 | $1.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.52 / $2.52 / $2.52
| Facility | | $2.52 | $2.52 | $2.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.20 / $2.20 / $3.50
| Professional | | $2.20 | $2.20 | $3.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.18 / $3.33 / $3.33
| Professional | | $3.18 | $3.33 | $3.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.23 / $3.18 / $4.45
| Professional | | $2.23 | $3.18 | $4.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.20 / $2.27 / $3.50
| Professional | | $2.20 | $2.27 | $3.50 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.17 / $2.65 / $3.03
| Professional | | $2.17 | $2.65 | $3.03 |