- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.64 / $16.36 / $192.95
| Facility | | $13.64 | $16.36 | $192.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.84 / $22.70 / $62.00
| Professional | | $10.84 | $22.70 | $62.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.42 / $9.42 / $9.42
| Professional | | $9.42 | $9.42 | $9.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.51 / $25.73 / $30.11
| Professional | | $19.51 | $25.73 | $30.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.53 / $19.84 / $23.14
| Professional | | $16.53 | $19.84 | $23.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.92 / $19.84 / $24.80
| Professional | | $9.92 | $19.84 | $24.80 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.60 / $20.73 / $23.21
| Professional | | $17.60 | $20.73 | $23.21 |