- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.32 / $19.32 / $19.32
| Facility | | $19.32 | $19.32 | $19.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.54 / $8.30 / $19.94
| Professional | | $2.54 | $8.30 | $19.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.32 / $19.32 / $19.32
| Facility | | $19.32 | $19.32 | $19.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.05 / $6.05 / $6.05
| Professional | | $6.05 | $6.05 | $6.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.04 / $23.04 / $23.04
| Professional | | $23.04 | $23.04 | $23.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.65 / $7.26 / $8.46
| Professional | | $6.65 | $7.26 | $8.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.05 / $6.05 / $18.93
| Professional | | $6.05 | $6.05 | $18.93 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.92 / $12.70 / $19.09
| Professional | | $7.92 | $12.70 | $19.09 |