- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.56 / $16.50 / $21.18
| Facility | | $14.56 | $16.50 | $21.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.41 / $24.23 / $119.00
| Professional | | $20.41 | $24.23 | $119.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.94 / $21.18 / $21.18
| Professional | | $13.94 | $21.18 | $21.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.69 / $37.86 / $44.33
| Professional | | $28.69 | $37.86 | $44.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.64 / $21.18 / $26.48
| Professional | | $17.64 | $21.18 | $26.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.41 / $21.18 / $34.26
| Professional | | $7.41 | $21.18 | $34.26 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.77 / $32.06 / $44.39
| Professional | | $19.77 | $32.06 | $44.39 |