- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.82 / $19.82 / $19.82
| Facility | | $19.82 | $19.82 | $19.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.82 / $19.82 / $19.82
| Facility | | $19.82 | $19.82 | $19.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.50 / $4.50 / $4.50
| Professional | | $4.50 | $4.50 | $4.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.83 / $9.83 / $9.83
| Professional | | $9.83 | $9.83 | $9.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.95 / $5.40 / $6.30
| Professional | | $4.95 | $5.40 | $6.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.50 / $6.75 / $8.07
| Professional | | $4.50 | $6.75 | $8.07 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.61 / $9.05 / $16.07
| Professional | | $5.61 | $9.05 | $16.07 |