- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.58 / $86.85 / $170.72
| Facility | | $11.58 | $86.85 | $170.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.79 / $13.63 / $25.48
| Professional | | $10.79 | $13.63 | $25.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.82 / $14.87 / $14.87
| Professional | | $9.82 | $14.87 | $14.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.17 / $26.60 / $31.11
| Professional | | $20.17 | $26.60 | $31.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.39 / $14.87 / $18.59
| Professional | | $12.39 | $14.87 | $18.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.20 / $14.87 / $24.04
| Professional | | $5.20 | $14.87 | $24.04 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.39 / $22.33 / $31.16
| Professional | | $12.39 | $22.33 | $31.16 |