- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.89 / $5.75 / $77.62
| Facility | | $3.89 | $5.75 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.51 / $4.17 / $5.25
| Professional | | $2.51 | $4.17 | $5.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.72 / $3.72 / $5.75
| Professional | | $3.72 | $3.72 | $5.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.13 / $10.47 / $11.75
| Professional | | $8.13 | $10.47 | $11.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.79 / $5.75 / $8.71
| Professional | | $4.79 | $5.75 | $8.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.00 / $6.61 / $9.12
| Professional | | $2.00 | $6.61 | $9.12 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.79 / $8.51 / $12.02
| Professional | | $4.79 | $8.51 | $12.02 |