- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.96 / $1.96 / $1.96
| Professional | | $1.96 | $1.96 | $1.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.18 / $3.18 / $3.18
| Facility | | $3.18 | $3.18 | $3.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.83 / $2.83 / $4.41
| Professional | | $2.83 | $2.83 | $4.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.01 / $4.20 / $4.20
| Professional | | $4.01 | $4.20 | $4.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.74 / $4.01 / $5.61
| Professional | | $2.74 | $4.01 | $5.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.44 / $3.18 / $4.41
| Professional | | $2.44 | $3.18 | $4.41 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.23 / $3.34 / $3.82
| Professional | | $3.23 | $3.34 | $3.82 |