- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.40 / $18.55 / $23.33
| Professional | | $14.40 | $18.55 | $23.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.72 / $66.00 / $107.04
| Professional | | $21.72 | $66.00 | $107.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.65 / $27.81 / $34.86
| Professional | | $23.65 | $27.81 | $34.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.12 / $23.13 / $25.14
| Professional | | $22.12 | $23.13 | $25.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.95 / $21.29 / $34.32
| Professional | | $15.95 | $21.29 | $34.32 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.34 / $27.03 / $250.00
| Professional | | $18.34 | $27.03 | $250.00 |