- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.02 / $14.45 / $128.82
| Facility | | $12.02 | $14.45 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.96 / $12.88 / $17.78
| Professional | | $10.96 | $12.88 | $17.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.48 / $11.48 / $17.78
| Professional | | $11.48 | $11.48 | $17.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.12 / $32.36 / $36.31
| Professional | | $25.12 | $32.36 | $36.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.79 / $17.78 / $28.84
| Professional | | $14.79 | $17.78 | $28.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.17 / $20.42 / $28.84
| Professional | | $6.17 | $20.42 | $28.84 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.79 / $26.30 / $37.15
| Professional | | $14.79 | $26.30 | $37.15 |