- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.56 / $15.56 / $15.56
| Facility | | $15.56 | $15.56 | $15.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.56 / $15.56 / $15.56
| Facility | | $15.56 | $15.56 | $15.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.40 / $4.40 / $4.40
| Professional | | $4.40 | $4.40 | $4.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.10 / $8.10 / $8.10
| Professional | | $8.10 | $8.10 | $8.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.84 / $5.28 / $6.16
| Professional | | $4.84 | $5.28 | $6.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.40 / $6.60 / $6.66
| Professional | | $4.40 | $6.60 | $6.66 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.68 / $10.62 / $22.59
| Professional | | $4.68 | $10.62 | $22.59 |