- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.65 / $6.54 / $14.40
| Professional | | $4.65 | $6.54 | $14.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.85 / $65.00 / $107.03
| Professional | | $7.85 | $65.00 | $107.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.04 / $6.87 / $8.14
| Professional | | $6.04 | $6.87 | $8.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.47 / $8.86 / $9.63
| Professional | | $8.47 | $8.86 | $9.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.05 / $7.85 / $11.67
| Professional | | $6.05 | $7.85 | $11.67 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.69 / $9.73 / $250.00
| Professional | | $6.69 | $9.73 | $250.00 |