- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.78 / $9.11 / $9.34
| Professional | | $8.78 | $9.11 | $9.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.34 / $9.34 / $13.86
| Professional | | $9.34 | $9.34 | $13.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.55 / $13.55 / $13.55
| Professional | | $13.55 | $13.55 | $13.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.00 / $5.00 / $670.00
| Professional | | $5.00 | $5.00 | $670.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.57 / $9.16 / $13.74
| Professional | | $8.57 | $9.16 | $13.74 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.84 / $8.84 / $14.06
| Professional | | $8.84 | $8.84 | $14.06 |