- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.76 / $4.76 / $4.76
| Professional | | $4.76 | $4.76 | $4.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.36 / $8.36 / $8.36
| Facility | | $8.36 | $8.36 | $8.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.91 / $6.91 / $11.59
| Professional | | $6.91 | $6.91 | $11.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.54 / $11.04 / $11.04
| Professional | | $10.54 | $11.04 | $11.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.38 / $10.54 / $14.76
| Professional | | $7.38 | $10.54 | $14.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.94 / $8.36 / $11.59
| Professional | | $5.94 | $8.36 | $11.59 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.19 / $8.77 / $10.02
| Professional | | $7.19 | $8.77 | $10.02 |