- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.75 / $15.59 / $20.00
| Facility | | $13.75 | $15.59 | $20.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.28 / $22.89 / $120.00
| Professional | | $19.28 | $22.89 | $120.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.15 / $20.00 / $20.00
| Professional | | $13.15 | $20.00 | $20.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.09 / $35.74 / $41.81
| Professional | | $27.09 | $35.74 | $41.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.67 / $20.00 / $25.01
| Professional | | $16.67 | $20.00 | $25.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.00 / $20.00 / $32.38
| Professional | | $7.00 | $20.00 | $32.38 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.67 / $30.28 / $41.92
| Professional | | $18.67 | $30.28 | $41.92 |