- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24.94 / $24.94 / $24.94
| Facility | | $24.94 | $24.94 | $24.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.28 / $13.28 / $13.28
| Professional | | $13.28 | $13.28 | $13.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24.95 / $24.95 / $24.95
| Facility | | $24.95 | $24.95 | $24.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.29 / $13.29 / $13.29
| Professional | | $13.29 | $13.29 | $13.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.97 / $18.97 / $18.97
| Professional | | $18.97 | $18.97 | $18.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.62 / $15.95 / $18.60
| Professional | | $14.62 | $15.95 | $18.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.29 / $15.59 / $19.94
| Professional | | $13.29 | $15.59 | $19.94 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.48 / $15.60 / $16.76
| Professional | | $12.48 | $15.60 | $16.76 |