- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.91 / $30.04 / $61.93
| Professional | | $7.91 | $30.04 | $61.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.46 / $24.07 / $24.07
| Professional | | $20.46 | $24.07 | $24.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.49 / $35.24 / $43.31
| Professional | | $28.49 | $35.24 | $43.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.36 / $21.40 / $24.96
| Professional | | $18.36 | $21.40 | $24.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.55 / $19.55 / $24.07
| Professional | | $19.55 | $19.55 | $24.07 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.94 / $26.02 / $41.47
| Professional | | $16.94 | $26.02 | $41.47 |