- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.50 / $21.00 / $135.58
| Facility | | $17.50 | $21.00 | $135.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.91 / $15.91 / $15.91
| Professional | | $15.91 | $15.91 | $15.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.96 / $25.45 / $25.45
| Professional | | $12.96 | $25.45 | $25.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.77 / $35.29 / $41.33
| Professional | | $26.77 | $35.29 | $41.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.21 / $25.45 / $31.82
| Professional | | $21.21 | $25.45 | $31.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.91 / $25.45 / $31.93
| Professional | | $8.91 | $25.45 | $31.93 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.76 / $30.30 / $42.55
| Professional | | $23.76 | $30.30 | $42.55 |