- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.20 / $32.38 / $32.38
| Professional | | $31.20 | $32.38 | $32.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.75 / $64.50 / $104.57
| Professional | | $37.75 | $64.50 | $104.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.61 / $30.00 / $42.00
| Professional | | $25.61 | $30.00 | $42.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.33 / $26.54 / $33.68
| Professional | | $24.33 | $26.54 | $33.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.70 / $29.50 / $35.09
| Professional | | $25.70 | $29.50 | $35.09 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.57 / $20.83 / $44.20
| Professional | | $19.57 | $20.83 | $44.20 |