- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.19 / $14.63 / $143.69
| Facility | | $12.19 | $14.63 | $143.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.83 / $7.83 / $14.77
| Professional | | $7.83 | $7.83 | $14.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.78 / $17.73 / $17.73
| Professional | | $11.78 | $17.73 | $17.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.03 / $31.70 / $37.11
| Professional | | $24.03 | $31.70 | $37.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.78 / $17.73 / $22.17
| Professional | | $14.78 | $17.73 | $22.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.21 / $17.73 / $28.70
| Professional | | $6.21 | $17.73 | $28.70 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.55 / $26.86 / $37.19
| Professional | | $16.55 | $26.86 | $37.19 |