- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.46 / $5,076.06 / $5,076.06
| Facility | | $12.46 | $5,076.06 | $5,076.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.55 / $963.80 / $2,772.69
| Professional | | $6.55 | $963.80 | $2,772.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.46 / $12.46 / $12.46
| Facility | | $12.46 | $12.46 | $12.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.25 / $6.25 / $6.25
| Professional | | $6.25 | $6.25 | $6.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.44 / $9.44 / $9.44
| Professional | | $9.44 | $9.44 | $9.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.15 / $7.80 / $9.10
| Professional | | $7.15 | $7.80 | $9.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.50 / $7.77 / $9.75
| Professional | | $6.50 | $7.77 | $9.75 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.90 / $6.58 / $8.15
| Professional | | $4.90 | $6.58 | $8.15 |