- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.17 / $9.17 / $9.17
| Professional | | $9.17 | $9.17 | $9.17 |
- 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
- $15.39 / $29.63 / $29.63
| Professional | | $15.39 | $29.63 | $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
- Facility
- Modifier
- Low / Median / High Price
- $12.18 / $12.18 / $12.31
| Facility | | $12.18 | $12.18 | $12.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.77 / $21.41 / $29.63
| Professional | | $18.77 | $21.41 | $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 |