- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.00 / $16.28 / $32.67
| Professional | | $12.00 | $16.28 | $32.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.23 / $25.43 / $30.51
| Professional | | $19.23 | $25.43 | $30.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.89 / $49.99 / $56.65
| Professional | | $42.89 | $49.99 | $56.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.75 / $21.56 / $25.43
| Professional | | $11.75 | $21.56 | $25.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,078.00 / $1,078.00 / $1,078.00
| Facility | | $1,078.00 | $1,078.00 | $1,078.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.75 / $25.43 / $38.15
| Professional | | $20.75 | $25.43 | $38.15 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.84 / $23.58 / $38.63
| Professional | | $9.84 | $23.58 | $38.63 |