- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.89 / $16.88 / $21.66
| Facility | | $14.89 | $16.88 | $21.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.88 / $24.78 / $137.00
| Professional | | $20.88 | $24.78 | $137.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.33 / $21.66 / $21.66
| Professional | | $14.33 | $21.66 | $21.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.36 / $38.72 / $45.33
| Professional | | $29.36 | $38.72 | $45.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.05 / $21.66 / $27.08
| Professional | | $18.05 | $21.66 | $27.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.66 / $21.66 / $35.04
| Professional | | $21.66 | $21.66 | $35.04 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.22 / $32.79 / $45.41
| Professional | | $20.22 | $32.79 | $45.41 |