- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.38 / $6.15 / $14.71
| Professional | | $5.38 | $6.15 | $14.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.26 / $23.83 / $23.83
| Professional | | $10.26 | $23.83 | $23.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.66 / $22.68 / $22.68
| Professional | | $21.66 | $22.68 | $22.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.32 / $30.32 / $30.32
| Professional | | $30.32 | $30.32 | $30.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.71 / $23.83 / $27.00
| Professional | | $9.71 | $23.83 | $27.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.78 / $18.04 / $20.61
| Professional | | $14.78 | $18.04 | $20.61 |