- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.78 / $14.78 / $14.78
| Professional | | $14.78 | $14.78 | $14.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.41 / $21.41 / $21.41
| Facility | | $21.41 | $21.41 | $21.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.45 / $18.45 / $29.63
| Professional | | $18.45 | $18.45 | $29.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.94 / $28.21 / $28.21
| Professional | | $26.94 | $28.21 | $28.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.16 / $26.94 / $37.72
| Professional | | $16.16 | $26.94 | $37.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.32 / $20.48 / $29.63
| Professional | | $16.32 | $20.48 | $29.63 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.71 / $22.45 / $25.64
| Professional | | $21.71 | $22.45 | $25.64 |