- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.90 / $11.22 / $14.40
| Facility | | $9.90 | $11.22 | $14.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.81 / $10.81 / $10.81
| Professional | | $10.81 | $10.81 | $10.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.42 / $14.40 / $14.40
| Professional | | $9.42 | $14.40 | $14.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.51 / $25.73 / $30.11
| Professional | | $19.51 | $25.73 | $30.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.00 / $14.40 / $18.00
| Professional | | $12.00 | $14.40 | $18.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.04 / $14.40 / $23.30
| Professional | | $5.04 | $14.40 | $23.30 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.44 / $21.81 / $30.20
| Professional | | $13.44 | $21.81 | $30.20 |