- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.00 / $11.33 / $14.54
| Facility | | $10.00 | $11.33 | $14.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.41 / $6.41 / $12.11
| Professional | | $6.41 | $6.41 | $12.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.61 / $14.54 / $14.54
| Professional | | $9.61 | $14.54 | $14.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.69 / $25.98 / $30.46
| Professional | | $19.69 | $25.98 | $30.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.12 / $14.54 / $18.18
| Professional | | $12.12 | $14.54 | $18.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.09 / $14.54 / $23.53
| Professional | | $5.09 | $14.54 | $23.53 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.57 / $22.02 / $30.49
| Professional | | $13.57 | $22.02 | $30.49 |