- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.79 / $0.79 / $0.79
| Professional | | $0.79 | $0.79 | $0.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.29 / $2.29 / $2.29
| Facility | | $2.29 | $2.29 | $2.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.04 / $2.04 / $3.17
| Professional | | $2.04 | $2.04 | $3.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.88 / $3.02 / $3.02
| Professional | | $2.88 | $3.02 | $3.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.02 / $2.88 / $4.03
| Professional | | $2.02 | $2.88 | $4.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.76 / $3.17 / $3.60
| Professional | | $1.76 | $3.17 | $3.60 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.48 / $2.33 / $2.74
| Professional | | $1.48 | $2.33 | $2.74 |