- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.00 / $11.67 / $75.00
| Professional | | $3.00 | $11.67 | $75.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.44 / $38.44 / $38.44
| Professional | | $38.44 | $38.44 | $38.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.03 / $22.00 / $27.50
| Professional | | $18.03 | $22.00 | $27.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.32 / $21.08 / $24.60
| Professional | | $19.32 | $21.08 | $24.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.75 / $21.96 / $23.24
| Professional | | $16.75 | $21.96 | $23.24 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.67 / $15.67 / $18.44
| Professional | | $15.67 | $15.67 | $18.44 |