- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.64 / $2.64 / $2.64
| Professional | | $2.64 | $2.64 | $2.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7.35 / $7.35 / $7.35
| Facility | | $7.35 | $7.35 | $7.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.63 / $6.63 / $10.18
| Professional | | $6.63 | $6.63 | $10.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.25 / $9.69 / $9.69
| Professional | | $9.25 | $9.69 | $9.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.24 / $9.25 / $12.95
| Professional | | $6.24 | $9.25 | $12.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.50 / $7.35 / $10.18
| Professional | | $5.50 | $7.35 | $10.18 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.32 / $7.71 / $8.80
| Professional | | $6.32 | $7.71 | $8.80 |