- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26.60 / $45.90 / $57.33
| Facility | | $26.60 | $45.90 | $57.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.29 / $13.29 / $13.29
| Facility | | $13.29 | $13.29 | $13.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.60 / $5.60 / $5.60
| Professional | | $5.60 | $5.60 | $5.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.96 / $5.96 / $5.96
| Professional | | $5.96 | $5.96 | $5.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.16 / $6.72 / $7.84
| Professional | | $6.16 | $6.72 | $7.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.88 / $5.60 / $8.40
| Professional | | $4.88 | $5.60 | $8.40 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.96 / $5.19 / $18.75
| Professional | | $3.96 | $5.19 | $18.75 |