- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.08 / $2.83 / $6.50
| Professional | | $2.08 | $2.83 | $6.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.42 / $4.88 / $16.30
| Professional | | $3.42 | $4.88 | $16.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.75 / $5.45 / $6.43
| Professional | | $4.75 | $5.45 | $6.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.13 / $4.68 / $5.46
| Professional | | $4.13 | $4.68 | $5.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.20 / $3.45 / $4.88
| Professional | | $2.20 | $3.45 | $4.88 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.22 / $3.03 / $6.22
| Professional | | $2.22 | $3.03 | $6.22 |