- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.55 / $11.45 / $170.84
| Facility | | $9.55 | $11.45 | $170.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.23 / $13.88 / $13.88
| Professional | | $9.23 | $13.88 | $13.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.80 / $24.80 / $29.05
| Professional | | $18.80 | $24.80 | $29.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.57 / $13.88 / $17.36
| Professional | | $11.57 | $13.88 | $17.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.86 / $13.88 / $22.46
| Professional | | $4.86 | $13.88 | $22.46 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.96 / $21.01 / $29.09
| Professional | | $12.96 | $21.01 | $29.09 |