- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.98 / $292.00 / $438.44
| Facility | | $120.98 | $292.00 | $438.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.20 / $10.70 / $13.62
| Professional | | $7.20 | $10.70 | $13.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.12 / $8.59 / $10.69
| Professional | | $6.12 | $8.59 | $10.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.04 / $24.21 / $31.70
| Professional | | $21.04 | $24.21 | $31.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.01 / $8.24 / $9.61
| Professional | | $7.01 | $8.24 | $9.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.01 / $8.59 / $19.00
| Professional | | $7.01 | $8.59 | $19.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.42 / $11.29 / $21.62
| Professional | | $7.42 | $11.29 | $21.62 |