- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.63 / $6.38 / $8.18
| Facility | | $5.63 | $6.38 | $8.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.82 / $7.95 / $49.00
| Professional | | $6.82 | $7.95 | $49.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.50 / $8.18 / $8.18
| Professional | | $5.50 | $8.18 | $8.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.07 / $14.61 / $17.11
| Professional | | $11.07 | $14.61 | $17.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.82 / $8.18 / $10.23
| Professional | | $6.82 | $8.18 | $10.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.86 / $8.18 / $13.24
| Professional | | $2.86 | $8.18 | $13.24 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.82 / $12.28 / $17.14
| Professional | | $6.82 | $12.28 | $17.14 |