- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.00 / $20.00 / $29.70
| Professional | | $15.00 | $20.00 | $29.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.65 / $20.65 / $20.65
| Professional | | $20.65 | $20.65 | $20.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.78 / $19.78 / $22.35
| Professional | | $19.78 | $19.78 | $22.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.57 / $21.98 / $31.32
| Professional | | $20.57 | $21.98 | $31.32 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.35 / $18.35 / $21.59
| Professional | | $18.35 | $18.35 | $21.59 |