- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.99 / $31.20 / $75.66
| Facility | | $3.99 | $31.20 | $75.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.20 / $4.26 / $4.70
| Professional | | $3.20 | $4.26 | $4.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.75 / $5.12 / $5.12
| Professional | | $2.75 | $5.12 | $5.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.80 / $7.65 / $8.91
| Professional | | $5.80 | $7.65 | $8.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.26 / $5.12 / $6.41
| Professional | | $4.26 | $5.12 | $6.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.56 / $5.12 / $6.88
| Professional | | $2.56 | $5.12 | $6.88 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.78 / $6.45 / $9.18
| Professional | | $4.78 | $6.45 | $9.18 |