- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.15 / $9.31 / $19.39
| Professional | | $8.15 | $9.31 | $19.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.09 / $32.44 / $32.44
| Professional | | $15.09 | $32.44 | $32.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.49 / $30.88 / $30.88
| Professional | | $29.49 | $30.88 | $30.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.15 / $41.15 / $41.15
| Professional | | $41.15 | $41.15 | $41.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.77 / $29.20 / $36.39
| Professional | | $9.77 | $29.20 | $36.39 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.71 / $24.36 / $27.90
| Professional | | $19.71 | $24.36 | $27.90 |