- 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
- $8.91 / $12.02 / $16.98
| Professional | | $8.91 | $12.02 | $16.98 |
- 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
- $23.44 / $30.20 / $33.11
| Professional | | $23.44 | $30.20 | $33.11 |
- 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 / $18.20 / $27.54
| Professional | | $5.01 | $18.20 | $27.54 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.23 / $16.22 / $26.92
| Professional | | $10.23 | $16.22 | $26.92 |