- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.88 / $25.70 / $34.67
| Professional | | $21.88 | $25.70 | $34.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.54 / $33.88 / $128.82
| Professional | | $27.54 | $33.88 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.15 / $42.66 / $56.23
| Professional | | $37.15 | $42.66 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.92 / $32.36 / $40.74
| Professional | | $26.92 | $32.36 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.95 / $30.90 / $41.69
| Professional | | $19.95 | $30.90 | $41.69 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.42 / $33.88 / $57.54
| Professional | | $20.42 | $33.88 | $57.54 |