- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6.63 / $84.00 / $141.62
| Facility | | $6.63 | $84.00 | $141.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.03 / $5.96 / $8.03
| Professional | | $5.03 | $5.96 | $8.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.30 / $8.03 / $8.03
| Professional | | $5.30 | $8.03 | $8.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.88 / $14.36 / $16.85
| Professional | | $10.88 | $14.36 | $16.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.70 / $8.03 / $10.05
| Professional | | $6.70 | $8.03 | $10.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.81 / $8.03 / $13.00
| Professional | | $2.81 | $8.03 | $13.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.70 / $12.07 / $16.85
| Professional | | $6.70 | $12.07 | $16.85 |