- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.23 / $16.98 / $199.53
| Facility | | $10.23 | $16.98 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.98 / $10.96 / $27.54
| Professional | | $3.98 | $10.96 | $27.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.76 / $7.76 / $14.79
| Professional | | $7.76 | $7.76 | $14.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.98 / $21.88 / $23.99
| Professional | | $16.98 | $21.88 | $23.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.59 / $14.79 / $24.55
| Professional | | $12.59 | $14.79 | $24.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.25 / $14.79 / $19.05
| Professional | | $5.25 | $14.79 | $19.05 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.13 / $18.20 / $25.70
| Professional | | $14.13 | $18.20 | $25.70 |