- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.25 / $2.25 / $2.25
| Professional | | $2.25 | $2.25 | $2.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.30 / $4.30 / $4.30
| Facility | | $4.30 | $4.30 | $4.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.60 / $3.60 / $5.96
| Professional | | $2.60 | $3.60 | $5.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.42 / $5.68 / $5.68
| Professional | | $5.42 | $5.68 | $5.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.79 / $5.42 / $7.59
| Professional | | $3.79 | $5.42 | $7.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.81 / $4.30 / $5.96
| Professional | | $2.81 | $4.30 | $5.96 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.71 / $4.51 / $5.16
| Professional | | $3.71 | $4.51 | $5.16 |