- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.42 / $9.42 / $9.42
| Professional | | $9.42 | $9.42 | $9.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.62 / $21.62 / $21.62
| Facility | | $21.62 | $21.62 | $21.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.80 / $15.80 / $29.93
| Professional | | $15.80 | $15.80 | $29.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.21 / $28.49 / $28.49
| Professional | | $27.21 | $28.49 | $28.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.32 / $27.21 / $38.09
| Professional | | $16.32 | $27.21 | $38.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.97 / $21.62 / $29.93
| Professional | | $18.97 | $21.62 | $29.93 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.90 / $21.92 / $25.90
| Professional | | $11.90 | $21.92 | $25.90 |