- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.75 / $32.99 / $52.11
| Professional | | $17.75 | $32.99 | $52.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.71 / $33.71 / $33.71
| Professional | | $33.71 | $33.71 | $33.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $32.36
| Professional | | $32.36 | $32.36 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.98 / $35.97 / $51.26
| Professional | | $31.98 | $35.97 | $51.26 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.09 / $34.09 / $34.09
| Professional | | $34.09 | $34.09 | $34.09 |