- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.38 / $13.38 / $13.38
| Facility | | $13.38 | $13.38 | $13.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.38 / $13.38 / $13.38
| Facility | | $13.38 | $13.38 | $13.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.11 / $7.11 / $7.11
| Professional | | $7.11 | $7.11 | $7.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.80 / $10.80 / $10.80
| Professional | | $10.80 | $10.80 | $10.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.82 / $8.53 / $9.96
| Professional | | $7.82 | $8.53 | $9.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.11 / $8.88 / $10.67
| Professional | | $7.11 | $8.88 | $10.67 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.45 / $6.98 / $9.00
| Professional | | $2.45 | $6.98 | $9.00 |