- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.96 / $21.96 / $21.96
| Facility | | $21.96 | $21.96 | $21.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.74 / $9.74 / $9.74
| Professional | | $9.74 | $9.74 | $9.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.96 / $21.96 / $21.96
| Facility | | $21.96 | $21.96 | $21.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.64 / $9.64 / $9.64
| Professional | | $9.64 | $9.64 | $9.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.37 / $18.37 / $18.37
| Professional | | $18.37 | $18.37 | $18.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.61 / $11.57 / $13.50
| Professional | | $10.61 | $11.57 | $13.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.46 / $15.10 / $66.50
| Professional | | $14.46 | $15.10 | $66.50 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.66 / $12.61 / $20.84
| Professional | | $9.66 | $12.61 | $20.84 |