- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.98 / $16.77 / $230.37
| Facility | | $13.98 | $16.77 | $230.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.56 / $14.98 / $52.94
| Professional | | $14.56 | $14.98 | $52.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.35 / $20.32 / $20.32
| Professional | | $13.35 | $20.32 | $20.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.57 / $36.36 / $42.53
| Professional | | $27.57 | $36.36 | $42.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.94 / $20.32 / $25.41
| Professional | | $16.94 | $20.32 | $25.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.11 / $20.32 / $32.86
| Professional | | $7.11 | $20.32 | $32.86 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.94 / $30.53 / $42.61
| Professional | | $16.94 | $30.53 | $42.61 |