- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.85 / $19.05 / $141.25
| Facility | | $15.85 | $19.05 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.14 / $18.20 / $23.44
| Professional | | $15.14 | $18.20 | $23.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.14 / $15.14 / $23.44
| Professional | | $15.14 | $15.14 | $23.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.11 / $42.66 / $47.86
| Professional | | $33.11 | $42.66 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.50 / $23.44 / $38.02
| Professional | | $19.50 | $23.44 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.13 / $26.92 / $38.02
| Professional | | $8.13 | $26.92 | $38.02 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.50 / $34.67 / $48.98
| Professional | | $19.50 | $34.67 | $48.98 |