- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.72 / $7.72 / $7.72
| Professional | | $7.72 | $7.72 | $7.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.53 / $12.53 / $12.53
| Facility | | $12.53 | $12.53 | $12.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.17 / $11.17 / $17.36
| Professional | | $11.17 | $11.17 | $17.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.78 / $16.52 / $16.52
| Professional | | $15.78 | $16.52 | $16.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.05 / $15.78 / $22.09
| Professional | | $11.05 | $15.78 | $22.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.60 / $12.53 / $17.36
| Professional | | $9.60 | $12.53 | $17.36 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.54 / $12.71 / $15.02
| Professional | | $7.54 | $12.71 | $15.02 |