- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.11 / $8.11 / $8.11
| Professional | | $8.11 | $8.11 | $8.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.79 / $11.79 / $11.79
| Facility | | $11.79 | $11.79 | $11.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.42 / $11.42 / $16.30
| Professional | | $11.42 | $11.42 | $16.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.83 / $15.53 / $15.53
| Professional | | $14.83 | $15.53 | $15.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.38 / $14.83 / $20.76
| Professional | | $10.38 | $14.83 | $20.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.62 / $11.79 / $18.50
| Professional | | $10.62 | $11.79 | $18.50 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.13 / $12.35 / $14.11
| Professional | | $10.13 | $12.35 | $14.11 |