- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.91 / $4.47 / $10.11
| Professional | | $3.91 | $4.47 | $10.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.70 / $17.88 / $17.88
| Professional | | $5.70 | $17.88 | $17.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.25 / $17.02 / $17.02
| Professional | | $16.25 | $17.02 | $17.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.75 / $22.75 / $22.75
| Professional | | $22.75 | $22.75 | $22.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.84 / $15.19 / $20.27
| Professional | | $4.84 | $15.19 | $20.27 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.09 / $13.54 / $15.47
| Professional | | $11.09 | $13.54 | $15.47 |