- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.01 / $5.01 / $5.01
| Professional | | $5.01 | $5.01 | $5.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.34 / $8.34 / $8.34
| Facility | | $8.34 | $8.34 | $8.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.06 / $7.06 / $11.56
| Professional | | $7.06 | $7.06 | $11.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.51 / $11.01 / $11.01
| Professional | | $10.51 | $11.01 | $11.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.36 / $10.51 / $14.71
| Professional | | $7.36 | $10.51 | $14.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.02 / $10.40 / $11.56
| Professional | | $6.02 | $10.40 | $11.56 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.17 / $8.75 / $10.00
| Professional | | $7.17 | $8.75 | $10.00 |