- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.46 / $20.82 / $24.87
| Professional | | $14.46 | $20.82 | $24.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.21 / $20.14 / $30.43
| Professional | | $13.21 | $20.14 | $30.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.89 / $26.28 / $29.58
| Professional | | $22.89 | $26.28 | $29.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.77 / $26.77 / $34.08
| Professional | | $26.77 | $26.77 | $34.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.58 / $24.83 / $30.43
| Professional | | $12.58 | $24.83 | $30.43 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.39 / $25.07 / $39.47
| Professional | | $15.39 | $25.07 | $39.47 |