- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.73 / $16.73 / $16.73
| Facility | | $16.73 | $16.73 | $16.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.73 / $16.73 / $16.73
| Facility | | $16.73 | $16.73 | $16.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.14 / $6.14 / $6.14
| Professional | | $6.14 | $6.14 | $6.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.66 / $12.66 / $14.94
| Professional | | $12.66 | $12.66 | $14.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.75 / $7.37 / $8.59
| Professional | | $6.75 | $7.37 | $8.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.14 / $9.21 / $10.41
| Professional | | $6.14 | $9.21 | $10.41 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.51 / $8.32 / $10.83
| Professional | | $4.51 | $8.32 | $10.83 |