- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.95 / $3.54 / $80.54
| Facility | | $2.95 | $3.54 | $80.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.19 / $3.19 / $4.91
| Professional | | $3.19 | $3.19 | $4.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.75 / $2.75 / $2.75
| Professional | | $2.75 | $2.75 | $2.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.84 / $7.71 / $8.98
| Professional | | $5.84 | $7.71 | $8.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.58 / $4.30 / $5.37
| Professional | | $3.58 | $4.30 | $5.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.15 / $4.30 / $6.95
| Professional | | $2.15 | $4.30 | $6.95 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.45 / $6.70 / $7.11
| Professional | | $5.45 | $6.70 | $7.11 |