- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.96 / $13.18 / $15.85
| Facility | | $10.96 | $13.18 | $15.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.02 / $10.00 / $12.02
| Professional | | $3.02 | $10.00 | $12.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.07 / $4.07 / $15.85
| Professional | | $4.07 | $4.07 | $15.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.49 / $16.60 / $18.20
| Professional | | $13.49 | $16.60 | $18.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.49 / $15.85 / $19.95
| Professional | | $13.49 | $15.85 | $19.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.62 / $10.00 / $19.95
| Professional | | $5.62 | $10.00 | $19.95 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.94 / $11.22 / $20.89
| Professional | | $7.94 | $11.22 | $20.89 |