- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.25 / $17.10 / $184.13
| Facility | | $14.25 | $17.10 | $184.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.39 / $12.39 / $12.39
| Professional | | $12.39 | $12.39 | $12.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.72 / $20.72 / $20.72
| Professional | | $20.72 | $20.72 | $20.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.89 / $25.26 / $30.74
| Professional | | $19.89 | $25.26 | $30.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.27 / $20.72 / $25.91
| Professional | | $17.27 | $20.72 | $25.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.25 / $20.72 / $25.91
| Professional | | $7.25 | $20.72 | $25.91 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.68 / $23.17 / $38.86
| Professional | | $14.68 | $23.17 | $38.86 |