- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.21 / $3.21 / $3.21
| Professional | | $3.21 | $3.21 | $3.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.13 / $4.13 / $4.13
| Facility | | $4.13 | $4.13 | $4.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.53 / $4.53 / $5.73
| Professional | | $4.53 | $4.53 | $5.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.21 / $5.46 / $5.46
| Professional | | $5.21 | $5.46 | $5.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.65 / $5.21 / $7.29
| Professional | | $3.65 | $5.21 | $7.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.72 / $4.66 / $5.73
| Professional | | $3.72 | $4.66 | $5.73 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.55 / $4.34 / $4.96
| Professional | | $3.55 | $4.34 | $4.96 |