- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.57 / $11.86 / $12.92
| Professional | | $9.57 | $11.86 | $12.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.70 / $6.70 / $33.29
| Professional | | $6.70 | $6.70 | $33.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.27 / $31.70 / $31.70
| Professional | | $30.27 | $31.70 | $31.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.38 / $42.38 / $42.38
| Professional | | $42.38 | $42.38 | $42.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.45 / $9.94 / $37.74
| Professional | | $5.45 | $9.94 | $37.74 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.50 / $26.50 / $28.81
| Professional | | $26.50 | $26.50 | $28.81 |