- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.04 / $1.04 / $1.04
| Professional | | $1.04 | $1.04 | $1.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.00 / $3.00 / $3.00
| Facility | | $3.00 | $3.00 | $3.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.67 / $2.67 / $4.16
| Professional | | $2.67 | $2.67 | $4.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.78 / $3.96 / $3.96
| Professional | | $3.78 | $3.96 | $3.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.65 / $3.78 / $5.29
| Professional | | $2.65 | $3.78 | $5.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.29 / $3.00 / $4.16
| Professional | | $2.29 | $3.00 | $4.16 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.22 / $3.15 / $3.60
| Professional | | $2.22 | $3.15 | $3.60 |