- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.33 / $1.33 / $1.33
| Professional | | $1.33 | $1.33 | $1.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.31 / $2.31 / $2.31
| Facility | | $2.31 | $2.31 | $2.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.87 / $1.87 / $3.19
| Professional | | $1.87 | $1.87 | $3.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.90 / $3.04 / $3.04
| Professional | | $2.90 | $3.04 | $3.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.02 / $2.90 / $4.05
| Professional | | $2.02 | $2.90 | $4.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.56 / $2.87 / $3.19
| Professional | | $1.56 | $2.87 | $3.19 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.00 / $2.42 / $2.76
| Professional | | $2.00 | $2.42 | $2.76 |