- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.73 / $18.73 / $31.42
| Facility | | $18.73 | $18.73 | $31.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.89 / $13.52 / $18.70
| Professional | | $10.89 | $13.52 | $18.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.73 / $18.73 / $32.13
| Facility | | $18.73 | $18.73 | $32.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.92 / $65.00 / $107.03
| Professional | | $15.92 | $65.00 | $107.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.66 / $17.09 / $21.36
| Professional | | $13.66 | $17.09 | $21.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.96 / $16.46 / $19.23
| Professional | | $14.96 | $16.46 | $19.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.10 / $16.16 / $24.50
| Professional | | $12.10 | $16.16 | $24.50 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.01 / $19.27 / $250.00
| Professional | | $13.01 | $19.27 | $250.00 |