- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.63 / $5.50 / $7.97
| Professional | | $2.63 | $5.50 | $7.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.08 / $2.89 / $2.89
| Professional | | $1.08 | $2.89 | $2.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.63 / $2.75 / $2.75
| Professional | | $2.63 | $2.75 | $2.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.68 / $3.68 / $3.68
| Professional | | $3.68 | $3.68 | $3.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.87 / $2.46 / $3.29
| Professional | | $0.87 | $2.46 | $3.29 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.32 / $2.21 / $3.39
| Professional | | $1.32 | $2.21 | $3.39 |