- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.52 / $12.40 / $205.49
| Facility | | $8.52 | $12.40 | $205.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.64 / $9.19 / $12.40
| Professional | | $7.64 | $9.19 | $12.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.25 / $12.40 / $12.40
| Professional | | $8.25 | $12.40 | $12.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.78 / $22.13 / $25.90
| Professional | | $16.78 | $22.13 | $25.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.33 / $12.40 / $15.50
| Professional | | $10.33 | $12.40 | $15.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.34 / $12.40 / $20.05
| Professional | | $4.34 | $12.40 | $20.05 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.57 / $18.76 / $25.97
| Professional | | $11.57 | $18.76 | $25.97 |