- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.56 / $3.56 / $3.56
| Professional | | $3.56 | $3.56 | $3.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.28 / $8.28 / $8.28
| Facility | | $8.28 | $8.28 | $8.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.99 / $11.48 / $11.48
| Professional | | $5.99 | $11.48 | $11.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.44 / $10.93 / $10.93
| Professional | | $10.44 | $10.93 | $10.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.26 / $10.44 / $14.62
| Professional | | $6.26 | $10.44 | $14.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.28 / $8.28 / $11.48
| Professional | | $7.28 | $8.28 | $11.48 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.41 / $8.69 / $9.94
| Professional | | $8.41 | $8.69 | $9.94 |