- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7.55 / $67.20 / $109.80
| Facility | | $7.55 | $67.20 | $109.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.76 / $7.20 / $9.68
| Professional | | $6.76 | $7.20 | $9.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.48 / $9.68 / $9.68
| Professional | | $6.48 | $9.68 | $9.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.15 / $17.35 / $20.28
| Professional | | $13.15 | $17.35 | $20.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.07 / $9.68 / $12.11
| Professional | | $8.07 | $9.68 | $12.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.39 / $9.68 / $15.68
| Professional | | $3.39 | $9.68 | $15.68 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.07 / $14.55 / $20.30
| Professional | | $8.07 | $14.55 | $20.30 |