- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.21 / $11.21 / $11.21
| Professional | | $11.21 | $11.21 | $11.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28.13 / $28.13 / $28.13
| Facility | | $28.13 | $28.13 | $28.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.62 / $16.62 / $38.97
| Professional | | $16.62 | $16.62 | $38.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.43 / $37.10 / $37.10
| Professional | | $35.43 | $37.10 | $37.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.26 / $35.43 / $49.60
| Professional | | $21.26 | $35.43 | $49.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.98 / $28.13 / $38.97
| Professional | | $18.98 | $28.13 | $38.97 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.48 / $22.11 / $33.72
| Professional | | $15.48 | $22.11 | $33.72 |