- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.00 / $12.02 / $14.45
| Facility | | $10.00 | $12.02 | $14.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.03 / $8.91 / $10.96
| Professional | | $6.03 | $8.91 | $10.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.45 / $14.45 / $14.45
| Professional | | $14.45 | $14.45 | $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 / $12.02 / $18.20
| Professional | | $5.01 | $12.02 | $18.20 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.23 / $16.22 / $26.92
| Professional | | $10.23 | $16.22 | $26.92 |