- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.74 / $7.74 / $7.74
| Professional | | $7.74 | $7.74 | $7.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.59 / $12.59 / $12.59
| Facility | | $12.59 | $12.59 | $12.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.23 / $11.20 / $17.44
| Professional | | $9.23 | $11.20 | $17.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.85 / $16.60 / $16.60
| Professional | | $15.85 | $16.60 | $16.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.81 / $15.85 / $22.19
| Professional | | $10.81 | $15.85 | $22.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.63 / $12.59 / $17.44
| Professional | | $9.63 | $12.59 | $17.44 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.77 / $13.21 / $15.09
| Professional | | $12.77 | $13.21 | $15.09 |