- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.57 / $6.57 / $6.57
| Professional | | $6.57 | $6.57 | $6.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.55 / $11.55 / $11.55
| Facility | | $11.55 | $11.55 | $11.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.49 / $9.49 / $15.99
| Professional | | $9.49 | $9.49 | $15.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.54 / $15.23 / $15.23
| Professional | | $14.54 | $15.23 | $15.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.18 / $14.54 / $20.36
| Professional | | $10.18 | $14.54 | $20.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.38 / $5.18 / $5.18
| Facility | | $4.38 | $5.18 | $5.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.18 / $11.55 / $15.99
| Professional | | $8.18 | $11.55 | $15.99 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.71 / $12.11 / $13.84
| Professional | | $11.71 | $12.11 | $13.84 |