- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26.33 / $26.33 / $271.74
| Facility | | $26.33 | $26.33 | $271.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.95 / $15.69 / $55.72
| Professional | | $6.95 | $15.69 | $55.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.63 / $13.63 / $13.63
| Facility | | $13.63 | $13.63 | $13.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.96 / $6.96 / $6.96
| Professional | | $6.96 | $6.96 | $6.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.96 / $10.96 / $10.96
| Professional | | $10.96 | $10.96 | $10.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.65 / $8.35 / $9.74
| Professional | | $7.65 | $8.35 | $9.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.96 / $9.01 / $10.44
| Professional | | $6.96 | $9.01 | $10.44 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.90 / $8.25 / $9.69
| Professional | | $5.90 | $8.25 | $9.69 |