- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.84 / $20.12 / $134.11
| Facility | | $13.84 | $20.12 | $134.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.52 / $16.77 / $29.90
| Professional | | $14.52 | $16.77 | $29.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.35 / $20.12 / $20.12
| Professional | | $13.35 | $20.12 | $20.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.95 / $35.99 / $42.15
| Professional | | $28.95 | $35.99 | $42.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.77 / $20.12 / $23.48
| Professional | | $16.77 | $20.12 | $23.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.04 / $20.12 / $32.56
| Professional | | $7.04 | $20.12 | $32.56 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.77 / $30.24 / $42.19
| Professional | | $16.77 | $30.24 | $42.19 |