- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.27 / $1.45 / $3.49
| Professional | | $1.27 | $1.45 | $3.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.94 / $5.24 / $5.24
| Professional | | $1.94 | $5.24 | $5.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.76 / $4.98 / $4.98
| Professional | | $4.76 | $4.98 | $4.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.66 / $6.66 / $6.66
| Professional | | $6.66 | $6.66 | $6.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.58 / $4.45 / $5.94
| Professional | | $1.58 | $4.45 | $5.94 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.25 / $3.83 / $4.53
| Professional | | $2.25 | $3.83 | $4.53 |