- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.89 / $3.31 / $6.72
| Professional | | $2.89 | $3.31 | $6.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.51 / $15.54 / $15.54
| Professional | | $5.51 | $15.54 | $15.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.13 / $14.80 / $14.80
| Professional | | $14.13 | $14.80 | $14.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.78 / $19.78 / $19.78
| Professional | | $19.78 | $19.78 | $19.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.58 / $13.99 / $17.63
| Professional | | $3.58 | $13.99 | $17.63 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.64 / $11.77 / $13.45
| Professional | | $9.64 | $11.77 | $13.45 |