- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.71 / $121.40 / $180.90
| Facility | | $15.71 | $121.40 | $180.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.28 / $15.00 / $52.65
| Professional | | $14.28 | $15.00 | $52.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.35 / $13.35 / $13.35
| Professional | | $13.35 | $13.35 | $13.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.33 / $36.04 / $42.15
| Professional | | $27.33 | $36.04 | $42.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.80 / $20.16 / $25.20
| Professional | | $16.80 | $20.16 | $25.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.06 / $20.16 / $32.61
| Professional | | $7.06 | $20.16 | $32.61 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.80 / $25.82 / $33.38
| Professional | | $16.80 | $25.82 | $33.38 |