- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.79 / $16.76 / $21.52
| Facility | | $14.79 | $16.76 | $21.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.19 / $24.62 / $432.00
| Professional | | $18.19 | $24.62 | $432.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.17 / $21.52 / $21.52
| Professional | | $12.17 | $21.52 | $21.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.55 / $34.97 / $42.56
| Professional | | $27.55 | $34.97 | $42.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.93 / $21.52 / $26.90
| Professional | | $17.93 | $21.52 | $26.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.53 / $21.52 / $26.90
| Professional | | $7.53 | $21.52 | $26.90 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.24 / $24.21 / $38.75
| Professional | | $15.24 | $24.21 | $38.75 |