- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.39 / $13.45 / $14.40
| Professional | | $12.39 | $13.45 | $14.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.47 / $66.00 / $107.04
| Professional | | $17.47 | $66.00 | $107.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.51 / $18.09 / $22.91
| Professional | | $15.51 | $18.09 | $22.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.41 / $16.57 / $18.01
| Professional | | $14.41 | $16.57 | $18.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.66 / $15.52 / $24.80
| Professional | | $11.66 | $15.52 | $24.80 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.50 / $19.50 / $250.00
| Professional | | $13.50 | $19.50 | $250.00 |