- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.46 / $14.46 / $14.46
| Facility | | $14.46 | $14.46 | $14.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.72 / $14.40 / $14.98
| Professional | | $11.72 | $14.40 | $14.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.46 / $14.46 / $14.46
| Facility | | $14.46 | $14.46 | $14.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.51 / $89.84 / $113.01
| Professional | | $13.51 | $89.84 | $113.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.12 / $12.35 / $15.63
| Professional | | $11.12 | $12.35 | $15.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.77 / $11.50 / $20.00
| Professional | | $9.77 | $11.50 | $20.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.38 / $13.41 / $257.50
| Professional | | $8.38 | $13.41 | $257.50 |