- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.29 / $37.29 / $37.29
| Professional | | $37.29 | $37.29 | $37.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.93 / $46.93 / $47.68
| Professional | | $46.93 | $46.93 | $47.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.25 / $57.17 / $70.69
| Professional | | $52.25 | $57.17 | $70.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.29 / $45.05 / $52.56
| Professional | | $41.29 | $45.05 | $52.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.29 / $46.93 / $63.11
| Professional | | $38.29 | $46.93 | $63.11 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.65 / $47.99 / $66.09
| Professional | | $6.65 | $47.99 | $66.09 |