- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.96 / $21.96 / $21.96
| Facility | | $21.96 | $21.96 | $21.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.95 / $21.95 / $21.95
| Facility | | $21.95 | $21.95 | $21.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.83 / $6.83 / $6.83
| Professional | | $6.83 | $6.83 | $6.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.50 / $10.50 / $10.50
| Professional | | $10.50 | $10.50 | $10.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.51 / $8.19 / $9.56
| Professional | | $7.51 | $8.19 | $9.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.83 / $8.63 / $10.25
| Professional | | $6.83 | $8.63 | $10.25 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.69 / $11.81 / $27.96
| Professional | | $8.69 | $11.81 | $27.96 |