- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.45 / $17.93 / $119.03
| Facility | | $13.45 | $17.93 | $119.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.51 / $16.30 / $41.93
| Professional | | $14.51 | $16.30 | $41.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.96 / $19.55 / $19.55
| Professional | | $12.96 | $19.55 | $19.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.53 / $35.00 / $40.95
| Professional | | $26.53 | $35.00 | $40.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.30 / $19.55 / $24.45
| Professional | | $16.30 | $19.55 | $24.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.85 / $19.55 / $31.65
| Professional | | $6.85 | $19.55 | $31.65 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.30 / $29.39 / $41.00
| Professional | | $16.30 | $29.39 | $41.00 |