- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $453.40 / $453.40 / $453.40
| Facility | | $453.40 | $453.40 | $453.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.11 / $21.00 / $48.00
| Professional | | $0.11 | $21.00 | $48.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.11 / $0.11 / $0.14
| Professional | | $0.11 | $0.11 | $0.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.18 / $0.18 / $0.19
| Professional | | $0.18 | $0.18 | $0.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.11 / $0.14 / $0.16
| Professional | | $0.11 | $0.14 | $0.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.11 / $0.14 / $0.17
| Professional | | $0.11 | $0.14 | $0.17 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.14 / $0.14 / $0.15
| Professional | | $0.14 | $0.14 | $0.15 |