- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.63 / $10.91 / $14.00
| Facility | | $9.63 | $10.91 | $14.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.23 / $14.00 / $14.00
| Professional | | $9.23 | $14.00 | $14.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.98 / $25.05 / $29.32
| Professional | | $18.98 | $25.05 | $29.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.67 / $14.00 / $17.51
| Professional | | $11.67 | $14.00 | $17.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.90 / $14.00 / $22.66
| Professional | | $4.90 | $14.00 | $22.66 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.07 / $21.22 / $29.38
| Professional | | $13.07 | $21.22 | $29.38 |