- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.13 / $14.13 / $14.13
| Facility | | $14.13 | $14.13 | $14.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.94 / $10.96 / $14.45
| Professional | | $7.94 | $10.96 | $14.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.45 / $14.45 / $14.45
| Facility | | $14.45 | $14.45 | $14.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.37 / $5.37 / $14.45
| Professional | | $5.37 | $5.37 | $14.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.48 / $12.88 / $16.22
| Professional | | $11.48 | $12.88 | $16.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.77 / $10.23 / $20.89
| Professional | | $9.77 | $10.23 | $20.89 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.32 / $13.49 / $257.04
| Professional | | $8.32 | $13.49 | $257.04 |