- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.00 / $15.16 / $62.56
| Professional | | $3.00 | $15.16 | $62.56 |
- 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
- $13.29 / $22.00 / $27.50
| Professional | | $13.29 | $22.00 | $27.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.72 / $14.96 / $17.46
| Professional | | $13.72 | $14.96 | $17.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.33 / $15.59 / $20.91
| Professional | | $11.33 | $15.59 | $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 |