- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.29 / $1.29 / $1.29
| Professional | | $1.29 | $1.29 | $1.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.75 / $3.75 / $3.75
| Facility | | $3.75 | $3.75 | $3.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.35 / $5.21 / $5.21
| Professional | | $3.35 | $5.21 | $5.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.74 / $4.96 / $4.96
| Professional | | $4.74 | $4.96 | $4.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.32 / $4.74 / $6.64
| Professional | | $3.32 | $4.74 | $6.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.86 / $4.69 / $17.50
| Professional | | $2.86 | $4.69 | $17.50 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.48 / $3.81 / $4.51
| Professional | | $1.48 | $3.81 | $4.51 |