- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.86 / $15.86 / $15.86
| Facility | | $15.86 | $15.86 | $15.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.86 / $15.86 / $15.86
| Facility | | $15.86 | $15.86 | $15.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.01 / $9.01 / $9.01
| Professional | | $9.01 | $9.01 | $9.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.05 / $13.05 / $13.05
| Professional | | $13.05 | $13.05 | $13.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.91 / $10.81 / $12.61
| Professional | | $9.91 | $10.81 | $12.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.01 / $10.72 / $13.52
| Professional | | $9.01 | $10.72 | $13.52 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.78 / $9.65 / $11.71
| Professional | | $6.78 | $9.65 | $11.71 |