- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.10 / $18.10 / $115.03
| Facility | | $14.10 | $18.10 | $115.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.15 / $13.15 / $20.70
| Professional | | $11.15 | $13.15 | $20.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.98 / $18.10 / $18.10
| Professional | | $11.98 | $18.10 | $18.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.51 / $32.32 / $37.85
| Professional | | $24.51 | $32.32 | $37.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.08 / $18.10 / $22.62
| Professional | | $15.08 | $18.10 | $22.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.33 / $18.10 / $29.27
| Professional | | $6.33 | $18.10 | $29.27 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.08 / $27.17 / $37.90
| Professional | | $15.08 | $27.17 | $37.90 |