- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.86 / $15.43 / $64.17
| Facility | | $12.86 | $15.43 | $64.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.14 / $17.14 / $17.14
| Professional | | $17.14 | $17.14 | $17.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.37 / $18.71 / $18.71
| Professional | | $12.37 | $18.71 | $18.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.06 / $27.79 / $32.49
| Professional | | $21.06 | $27.79 | $32.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.59 / $18.71 / $23.39
| Professional | | $15.59 | $18.71 | $23.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.55 / $18.71 / $25.15
| Professional | | $6.55 | $18.71 | $25.15 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.46 / $23.52 / $33.67
| Professional | | $17.46 | $23.52 | $33.67 |