- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.42 / $5.42 / $5.42
| Professional | | $5.42 | $5.42 | $5.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.67 / $7.38 / $10.86
| Professional | | $3.67 | $7.38 | $10.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.12 / $8.19 / $10.73
| Professional | | $7.12 | $8.19 | $10.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.38 / $8.69 / $10.14
| Professional | | $7.38 | $8.69 | $10.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.48 / $8.27 / $12.58
| Professional | | $5.48 | $8.27 | $12.58 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.39 / $7.61 / $15.83
| Professional | | $5.39 | $7.61 | $15.83 |