- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.79 / $16.42 / $133.19
| Facility | | $12.79 | $16.42 | $133.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.15 / $13.68 / $18.78
| Professional | | $12.15 | $13.68 | $18.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.80 / $10.80 / $10.80
| Professional | | $10.80 | $10.80 | $10.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.24 / $29.33 / $34.28
| Professional | | $22.24 | $29.33 | $34.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.68 / $16.42 / $20.52
| Professional | | $13.68 | $16.42 | $20.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.75 / $16.42 / $26.55
| Professional | | $5.75 | $16.42 | $26.55 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.77 / $25.58 / $34.36
| Professional | | $20.77 | $25.58 | $34.36 |