- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.46 / $7.46 / $7.46
| Professional | | $7.46 | $7.46 | $7.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.88 / $16.88 / $16.88
| Facility | | $16.88 | $16.88 | $16.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.32 / $12.32 / $23.39
| Professional | | $12.32 | $12.32 | $23.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.26 / $22.26 / $22.26
| Professional | | $21.26 | $22.26 | $22.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.88 / $21.26 / $29.76
| Professional | | $14.88 | $21.26 | $29.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.92 / $16.88 / $26.51
| Professional | | $10.92 | $16.88 | $26.51 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.51 / $17.71 / $20.23
| Professional | | $14.51 | $17.71 | $20.23 |