- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.14 / $2.15 / $7.65
| Professional | | $2.14 | $2.15 | $7.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.08 / $11.84 / $11.84
| Professional | | $5.08 | $11.84 | $11.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.76 / $11.27 / $11.27
| Professional | | $10.76 | $11.27 | $11.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.06 / $15.06 / $15.06
| Professional | | $15.06 | $15.06 | $15.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.55 / $10.06 / $13.41
| Professional | | $4.55 | $10.06 | $13.41 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.41 / $8.66 / $10.24
| Professional | | $4.41 | $8.66 | $10.24 |