- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.83 / $18.10 / $33.18
| Professional | | $15.83 | $18.10 | $33.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.44 / $43.57 / $43.57
| Professional | | $32.44 | $43.57 | $43.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.61 / $41.48 / $41.48
| Professional | | $39.61 | $41.48 | $41.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.45 / $55.45 / $55.45
| Professional | | $55.45 | $55.45 | $55.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.47 / $39.21 / $52.02
| Professional | | $15.47 | $39.21 | $52.02 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.70 / $37.70 / $37.70
| Professional | | $37.70 | $37.70 | $37.70 |