- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.35 / $16.02 / $150.08
| Facility | | $13.35 | $16.02 | $150.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.10 / $17.80 / $22.21
| Professional | | $14.10 | $17.80 | $22.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.76 / $19.42 / $19.42
| Professional | | $12.76 | $19.42 | $19.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.29 / $34.68 / $40.61
| Professional | | $26.29 | $34.68 | $40.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.18 / $19.42 / $24.27
| Professional | | $16.18 | $19.42 | $24.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.80 / $19.42 / $31.41
| Professional | | $6.80 | $19.42 | $31.41 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.12 / $29.39 / $40.70
| Professional | | $18.12 | $29.39 | $40.70 |