- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.42 / $64.95 / $134.40
| Facility | | $12.42 | $64.95 | $134.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.06 / $15.05 / $43.52
| Professional | | $13.06 | $15.05 | $43.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.98 / $18.05 / $18.05
| Professional | | $11.98 | $18.05 | $18.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.45 / $32.26 / $37.79
| Professional | | $24.45 | $32.26 | $37.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.05 / $18.05 / $22.58
| Professional | | $15.05 | $18.05 | $22.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.02 / $18.05 / $29.23
| Professional | | $9.02 | $18.05 | $29.23 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.05 / $27.13 / $37.85
| Professional | | $15.05 | $27.13 | $37.85 |