- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.37 / $14.84 / $134.11
| Facility | | $12.37 | $14.84 | $134.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.56 / $13.07 / $404.86
| Professional | | $12.56 | $13.07 | $404.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.98 / $17.98 / $17.98
| Professional | | $11.98 | $17.98 | $17.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.36 / $32.14 / $37.64
| Professional | | $24.36 | $32.14 | $37.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.99 / $17.98 / $22.49
| Professional | | $14.99 | $17.98 | $22.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.30 / $17.98 / $29.10
| Professional | | $6.30 | $17.98 | $29.10 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.79 / $27.24 / $37.71
| Professional | | $16.79 | $27.24 | $37.71 |