- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.38 / $14.03 / $18.00
| Facility | | $12.38 | $14.03 | $18.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.40 / $18.00 / $18.00
| Professional | | $10.40 | $18.00 | $18.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.44 / $28.28 / $33.09
| Professional | | $21.44 | $28.28 | $33.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.00 / $18.00 / $22.50
| Professional | | $15.00 | $18.00 | $22.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.30 / $18.00 / $25.61
| Professional | | $6.30 | $18.00 | $25.61 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.80 / $23.96 / $33.75
| Professional | | $16.80 | $23.96 | $33.75 |