- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.54 / $25.54 / $25.54
| Facility | | $25.54 | $25.54 | $25.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.54 / $25.54 / $25.54
| Facility | | $25.54 | $25.54 | $25.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.39 / $7.39 / $7.39
| Professional | | $7.39 | $7.39 | $7.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.12 / $3.12 / $3.12
| Professional | | $3.12 | $3.12 | $3.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.13 / $8.86 / $10.35
| Professional | | $8.13 | $8.86 | $10.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.57 / $7.39 / $11.09
| Professional | | $2.57 | $7.39 | $11.09 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.41 / $2.54 / $5.52
| Professional | | $1.41 | $2.54 | $5.52 |