- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7.56 / $59.42 / $133.44
| Facility | | $7.56 | $59.42 | $133.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.78 / $7.33 / $9.71
| Professional | | $6.78 | $7.33 | $9.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.48 / $9.71 / $9.71
| Professional | | $6.48 | $9.71 | $9.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.44 / $16.41 / $19.14
| Professional | | $12.44 | $16.41 | $19.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.09 / $9.71 / $11.33
| Professional | | $8.09 | $9.71 | $11.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.40 / $9.71 / $14.82
| Professional | | $3.40 | $9.71 | $14.82 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.06 / $13.87 / $19.21
| Professional | | $9.06 | $13.87 | $19.21 |