- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.00 / $35.00 / $88.56
| Professional | | $10.00 | $35.00 | $88.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.14 / $18.14 / $18.14
| Professional | | $18.14 | $18.14 | $18.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.09 / $12.53 / $16.53
| Professional | | $11.09 | $12.53 | $16.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.98 / $18.53 / $21.62
| Professional | | $16.98 | $18.53 | $21.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.30 / $19.30 / $20.91
| Professional | | $13.30 | $19.30 | $20.91 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.80 / $11.80 / $13.88
| Professional | | $11.80 | $11.80 | $13.88 |