- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.13 / $77.15 / $179.00
| Facility | | $13.13 | $77.15 | $179.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.86 / $14.43 / $35.17
| Professional | | $13.86 | $14.43 | $35.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.56 / $19.09 / $19.09
| Professional | | $12.56 | $19.09 | $19.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.87 / $34.13 / $39.89
| Professional | | $25.87 | $34.13 | $39.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.91 / $19.09 / $23.87
| Professional | | $15.91 | $19.09 | $23.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.68 / $19.09 / $30.88
| Professional | | $6.68 | $19.09 | $30.88 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.91 / $28.66 / $40.00
| Professional | | $15.91 | $28.66 | $40.00 |