- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.14 / $4.55 / $23.95
| Facility | | $3.14 | $4.55 | $23.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.80 / $3.97 / $5.21
| Professional | | $3.80 | $3.97 | $5.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.75 / $4.55 / $4.55
| Professional | | $2.75 | $4.55 | $4.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.61 / $7.40 / $8.66
| Professional | | $5.61 | $7.40 | $8.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.80 / $4.55 / $5.70
| Professional | | $3.80 | $4.55 | $5.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.60 / $4.55 / $6.67
| Professional | | $1.60 | $4.55 | $6.67 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.26 / $6.25 / $8.66
| Professional | | $4.26 | $6.25 | $8.66 |