- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.25 / $2.25 / $2.25
| Professional | | $2.25 | $2.25 | $2.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.87 / $4.87 / $4.87
| Facility | | $4.87 | $4.87 | $4.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.51 / $3.51 / $6.73
| Professional | | $3.51 | $3.51 | $6.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.12 / $6.41 / $6.41
| Professional | | $6.12 | $6.41 | $6.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.67 / $6.12 / $8.57
| Professional | | $3.67 | $6.12 | $8.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.26 / $4.87 / $6.73
| Professional | | $4.26 | $4.87 | $6.73 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.93 / $5.09 / $5.83
| Professional | | $4.93 | $5.09 | $5.83 |