- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6.42 / $47.88 / $47.88
| Facility | | $6.42 | $47.88 | $47.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.91 / $5.98 / $10.68
| Professional | | $3.91 | $5.98 | $10.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.12 / $4.12 / $4.12
| Professional | | $4.12 | $4.12 | $4.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.43 / $11.13 / $13.02
| Professional | | $8.43 | $11.13 | $13.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.78 / $9.34 / $10.89
| Professional | | $7.78 | $9.34 | $10.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.27 / $9.34 / $11.67
| Professional | | $3.27 | $9.34 | $11.67 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.87 / $9.69 / $13.01
| Professional | | $7.87 | $9.69 | $13.01 |