- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.75 / $26.96 / $35.35
| Professional | | $20.75 | $26.96 | $35.35 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $25.11 / $25.11 / $25.11
| Professional | 25 | $25.11 | $25.11 | $25.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.58 / $31.84 / $47.28
| Professional | | $23.58 | $31.84 | $47.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.05 / $33.76 / $38.82
| Professional | | $30.05 | $33.76 | $38.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.76 / $30.04 / $38.22
| Professional | | $26.76 | $30.04 | $38.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.58 / $34.14 / $45.69
| Professional | | $24.58 | $34.14 | $45.69 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.40 / $34.06 / $34.65
| Professional | | $25.40 | $34.06 | $34.65 |