- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.18 / $23.18 / $23.18
| Facility | | $23.18 | $23.18 | $23.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.17 / $23.17 / $23.17
| Facility | | $23.17 | $23.17 | $23.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.98 / $10.98 / $10.98
| Professional | | $10.98 | $10.98 | $10.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.05 / $16.05 / $16.05
| Professional | | $16.05 | $16.05 | $16.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.08 / $13.17 / $15.37
| Professional | | $12.08 | $13.17 | $15.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.98 / $13.19 / $16.47
| Professional | | $10.98 | $13.19 | $16.47 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.34 / $12.06 / $14.70
| Professional | | $6.34 | $12.06 | $14.70 |