- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.88 / $11.20 / $14.38
| Facility | | $9.88 | $11.20 | $14.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.85 / $13.99 / $53.00
| Professional | | $13.85 | $13.99 | $53.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.42 / $14.38 / $14.38
| Professional | | $9.42 | $14.38 | $14.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.51 / $25.73 / $30.11
| Professional | | $19.51 | $25.73 | $30.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.98 / $14.38 / $17.97
| Professional | | $11.98 | $14.38 | $17.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.03 / $14.38 / $23.26
| Professional | | $5.03 | $14.38 | $23.26 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.42 / $21.78 / $30.15
| Professional | | $13.42 | $21.78 | $30.15 |