- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.86 / $12.89 / $192.67
| Facility | | $8.86 | $12.89 | $192.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.94 / $9.72 / $12.89
| Professional | | $7.94 | $9.72 | $12.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.44 / $12.89 / $12.89
| Professional | | $8.44 | $12.89 | $12.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.48 / $23.06 / $26.96
| Professional | | $17.48 | $23.06 | $26.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.74 / $12.89 / $16.11
| Professional | | $10.74 | $12.89 | $16.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.89 / $12.89 / $16.11
| Professional | | $12.89 | $12.89 | $16.11 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.74 / $19.36 / $27.02
| Professional | | $10.74 | $19.36 | $27.02 |