- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.13 / $11.75 / $199.53
| Facility | | $8.13 | $11.75 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.31 / $8.91 / $10.00
| Professional | | $3.31 | $8.91 | $10.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.77 / $9.77 / $11.75
| Professional | | $9.77 | $9.77 | $11.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.55 / $31.62 / $34.67
| Professional | | $24.55 | $31.62 | $34.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.77 / $11.75 / $14.79
| Professional | | $9.77 | $11.75 | $14.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.07 / $11.75 / $16.22
| Professional | | $4.07 | $11.75 | $16.22 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.92 / $14.45 / $47.86
| Professional | | $6.92 | $14.45 | $47.86 |