- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.91 / $3.38 / $3.71
| Professional | | $0.91 | $3.38 | $3.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.03 / $1.56 / $1.56
| Professional | | $1.03 | $1.56 | $1.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.53 / $12.07 / $12.07
| Professional | | $11.53 | $12.07 | $12.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.99 / $1.99 / $1.99
| Professional | | $1.99 | $1.99 | $1.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.80 / $1.33 / $2.13
| Professional | | $0.80 | $1.33 | $2.13 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.42 / $1.42 / $12.74
| Professional | | $1.42 | $1.42 | $12.74 |