- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.02 / $21.02 / $21.02
| Facility | | $21.02 | $21.02 | $21.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.03 / $21.03 / $21.03
| Facility | | $21.03 | $21.03 | $21.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.30 / $7.30 / $7.30
| Professional | | $7.30 | $7.30 | $7.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.74 / $13.74 / $13.74
| Professional | | $13.74 | $13.74 | $13.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.03 / $8.77 / $10.23
| Professional | | $8.03 | $8.77 | $10.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.31 / $10.97 / $11.29
| Professional | | $7.31 | $10.97 | $11.29 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.83 / $12.14 / $24.00
| Professional | | $8.83 | $12.14 | $24.00 |