- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.00 / $11.75 / $14.45
| Facility | | $10.00 | $11.75 | $14.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.94 / $10.72 / $10.96
| Professional | | $7.94 | $10.72 | $10.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.33 / $9.33 / $14.45
| Professional | | $9.33 | $9.33 | $14.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.89 / $26.92 / $29.51
| Professional | | $20.89 | $26.92 | $29.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.02 / $14.45 / $18.20
| Professional | | $12.02 | $14.45 | $18.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.01 / $16.60 / $23.44
| Professional | | $5.01 | $16.60 | $23.44 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.49 / $21.88 / $30.20
| Professional | | $13.49 | $21.88 | $30.20 |