- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $42.66 / $42.66 / $42.66
| Facility | | $42.66 | $42.66 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.08 / $8.91 / $12.88
| Professional | | $7.08 | $8.91 | $12.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.08 / $8.32 / $15.85
| Professional | | $7.08 | $8.32 | $15.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.96 / $12.02 / $13.49
| Professional | | $10.96 | $12.02 | $13.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.91 / $12.30 / $15.49
| Professional | | $8.91 | $12.30 | $15.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.08 / $9.77 / $13.18
| Professional | | $7.08 | $9.77 | $13.18 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.76 / $8.71 / $11.75
| Professional | | $7.76 | $8.71 | $11.75 |