- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.97 / $14.51 / $191.59
| Facility | | $9.97 | $14.51 | $191.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.38 / $10.97 / $35.65
| Professional | | $10.38 | $10.97 | $35.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.61 / $14.51 / $14.51
| Professional | | $9.61 | $14.51 | $14.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.64 / $25.92 / $30.30
| Professional | | $19.64 | $25.92 | $30.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.09 / $14.51 / $18.14
| Professional | | $12.09 | $14.51 | $18.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.08 / $14.51 / $23.47
| Professional | | $5.08 | $14.51 | $23.47 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.09 / $21.79 / $30.40
| Professional | | $12.09 | $21.79 | $30.40 |