- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.23 / $12.30 / $125.89
| Facility | | $10.23 | $12.30 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.91 / $11.22 / $14.79
| Professional | | $8.91 | $11.22 | $14.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.77 / $9.77 / $14.79
| Professional | | $9.77 | $9.77 | $14.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $27.54 / $30.20
| Professional | | $21.38 | $27.54 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.30 / $14.79 / $19.50
| Professional | | $12.30 | $14.79 | $19.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.25 / $17.38 / $23.99
| Professional | | $5.25 | $17.38 | $23.99 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.30 / $22.39 / $30.90
| Professional | | $12.30 | $22.39 | $30.90 |