- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.25 / $15.90 / $278.54
| Facility | | $13.25 | $15.90 | $278.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.80 / $19.27 / $22.05
| Professional | | $13.80 | $19.27 | $22.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.76 / $19.27 / $19.27
| Professional | | $12.76 | $19.27 | $19.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.11 / $34.43 / $40.29
| Professional | | $26.11 | $34.43 | $40.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.05 / $19.27 / $22.62
| Professional | | $16.05 | $19.27 | $22.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.75 / $19.27 / $31.18
| Professional | | $6.75 | $19.27 | $31.18 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.98 / $29.17 / $40.39
| Professional | | $17.98 | $29.17 | $40.39 |