- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.07 / $9.16 / $17.69
| Professional | | $7.07 | $9.16 | $17.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.26 / $18.03 / $34.28
| Professional | | $9.26 | $18.03 | $34.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.41 / $26.37 / $32.18
| Professional | | $22.41 | $26.37 | $32.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.14 / $27.42 / $31.99
| Professional | | $25.14 | $27.42 | $31.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.68 / $17.07 / $28.56
| Professional | | $8.68 | $17.07 | $28.56 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.94 / $9.94 / $9.94
| Professional | | $9.94 | $9.94 | $9.94 |