- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.87 / $14.25 / $202.01
| Facility | | $11.87 | $14.25 | $202.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.40 / $16.64 / $22.00
| Professional | | $14.40 | $16.64 | $22.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.39 / $17.27 / $17.27
| Professional | | $11.39 | $17.27 | $17.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.42 / $30.89 / $36.13
| Professional | | $23.42 | $30.89 | $36.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.39 / $17.27 / $21.59
| Professional | | $14.39 | $17.27 | $21.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.04 / $17.27 / $27.94
| Professional | | $6.04 | $17.27 | $27.94 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.12 / $26.14 / $36.20
| Professional | | $16.12 | $26.14 | $36.20 |