- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.28 / $4.28 / $6.10
| Professional | | $4.28 | $4.28 | $6.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.13 / $14.39 / $14.39
| Professional | | $7.13 | $14.39 | $14.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.82 / $10.28 / $13.70
| Professional | | $9.82 | $10.28 | $13.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.30 / $18.30 / $18.30
| Professional | | $18.30 | $18.30 | $18.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.92 / $12.23 / $16.30
| Professional | | $5.92 | $12.23 | $16.30 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.93 / $10.89 / $13.08
| Professional | | $8.93 | $10.89 | $13.08 |