- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.26 / $7.90 / $14.98
| Professional | | $6.26 | $7.90 | $14.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.23 / $58.00 / $112.19
| Professional | | $8.23 | $58.00 | $112.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.74 / $10.17 / $12.85
| Professional | | $8.74 | $10.17 | $12.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.24 / $7.57 / $8.23
| Professional | | $7.24 | $7.57 | $8.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.23 / $7.11 / $9.81
| Professional | | $5.23 | $7.11 | $9.81 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.35 / $8.48 / $250.00
| Professional | | $5.35 | $8.48 | $250.00 |