- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.51 / $37.52 / $213.40
| Facility | | $9.51 | $37.52 | $213.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.90 / $23.06 / $40.52
| Professional | | $9.90 | $23.06 | $40.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.23 / $9.23 / $9.23
| Professional | | $9.23 | $9.23 | $9.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.76 / $24.74 / $28.94
| Professional | | $18.76 | $24.74 | $28.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.53 / $13.84 / $17.30
| Professional | | $11.53 | $13.84 | $17.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.84 / $13.84 / $22.39
| Professional | | $4.84 | $13.84 | $22.39 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.53 / $26.60 / $29.82
| Professional | | $11.53 | $26.60 | $29.82 |