- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.05 / $4.05 / $4.05
| Professional | | $4.05 | $4.05 | $4.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.97 / $10.97 / $10.97
| Facility | | $10.97 | $10.97 | $10.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.14 / $15.19 / $15.19
| Professional | | $7.14 | $15.19 | $15.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.81 / $14.46 / $14.46
| Professional | | $13.81 | $14.46 | $14.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.28 / $13.81 / $19.32
| Professional | | $8.28 | $13.81 | $19.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7.28 / $7.28 / $7.47
| Facility | | $7.28 | $7.28 | $7.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.55 / $10.97 / $17.23
| Professional | | $6.55 | $10.97 | $17.23 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.04 / $8.63 / $13.15
| Professional | | $6.04 | $8.63 | $13.15 |