- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.92 / $32.96 / $59.25
| Professional | | $16.92 | $32.96 | $59.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.59 / $15.58 / $18.09
| Professional | | $12.59 | $15.58 | $18.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.53 / $16.50 / $18.80
| Professional | | $13.53 | $16.50 | $18.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.14 / $23.66 / $34.08
| Professional | | $19.14 | $23.66 | $34.08 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.50 / $12.75 / $15.00
| Professional | | $10.50 | $12.75 | $15.00 |