- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6.94 / $8.33 / $10.09
| Facility | | $6.94 | $8.33 | $10.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.41 / $8.41 / $58.00
| Professional | | $8.41 | $8.41 | $58.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.67 / $10.09 / $10.09
| Professional | | $6.67 | $10.09 | $10.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.66 / $18.02 / $21.06
| Professional | | $13.66 | $18.02 | $21.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.41 / $10.09 / $12.62
| Professional | | $8.41 | $10.09 | $12.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.53 / $10.09 / $16.32
| Professional | | $3.53 | $10.09 | $16.32 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.42 / $15.26 / $21.13
| Professional | | $9.42 | $15.26 | $21.13 |