- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.05 / $42.31 / $106.56
| Facility | | $8.05 | $42.31 | $106.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.18 / $9.47 / $21.82
| Professional | | $6.18 | $9.47 | $21.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.09 / $10.33 / $10.33
| Professional | | $5.09 | $10.33 | $10.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.27 / $13.55 / $15.87
| Professional | | $10.27 | $13.55 | $15.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.61 / $10.33 / $12.92
| Professional | | $8.61 | $10.33 | $12.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.17 / $10.33 / $12.92
| Professional | | $5.17 | $10.33 | $12.92 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.61 / $11.62 / $16.35
| Professional | | $8.61 | $11.62 | $16.35 |