- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.58 / $5.24 / $12.55
| Professional | | $4.58 | $5.24 | $12.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.75 / $20.32 / $20.32
| Professional | | $8.75 | $20.32 | $20.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.47 / $19.34 / $19.34
| Professional | | $18.47 | $19.34 | $19.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.86 / $25.86 / $25.86
| Professional | | $25.86 | $25.86 | $25.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.68 / $17.27 / $23.04
| Professional | | $5.68 | $17.27 | $23.04 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.62 / $14.88 / $17.57
| Professional | | $12.62 | $14.88 | $17.57 |