- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.94 / $16.94 / $16.94
| Facility | | $16.94 | $16.94 | $16.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.93 / $16.93 / $16.93
| Facility | | $16.93 | $16.93 | $16.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.86 / $2.86 / $3.19
| Professional | | $2.86 | $2.86 | $3.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.47 / $3.47 / $3.47
| Professional | | $3.47 | $3.47 | $3.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.19 / $3.82 / $4.46
| Professional | | $3.19 | $3.82 | $4.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.86 / $3.19 / $4.79
| Professional | | $2.86 | $3.19 | $4.79 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.88 / $9.63 / $12.64
| Professional | | $2.88 | $9.63 | $12.64 |