- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.63 / $15.46 / $176.66
| Facility | | $10.63 | $15.46 | $176.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.23 / $11.68 / $35.81
| Professional | | $11.23 | $11.68 | $35.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.21 / $15.46 / $15.46
| Professional | | $10.21 | $15.46 | $15.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.97 / $27.66 / $32.36
| Professional | | $20.97 | $27.66 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.88 / $15.46 / $19.32
| Professional | | $12.88 | $15.46 | $19.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.41 / $15.46 / $25.01
| Professional | | $5.41 | $15.46 | $25.01 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.88 / $23.22 / $32.40
| Professional | | $12.88 | $23.22 | $32.40 |