- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.94 / $0.94 / $0.94
| Professional | | $0.94 | $0.94 | $0.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.76 / $2.76 / $2.76
| Facility | | $2.76 | $2.76 | $2.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.46 / $2.46 / $3.84
| Professional | | $2.46 | $2.46 | $3.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.49 / $3.65 / $3.65
| Professional | | $3.49 | $3.65 | $3.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.37 / $3.49 / $4.88
| Professional | | $2.37 | $3.49 | $4.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.12 / $2.76 / $3.84
| Professional | | $2.12 | $2.76 | $3.84 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.80 / $2.90 / $3.32
| Professional | | $2.80 | $2.90 | $3.32 |