- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.85 / $51.72 / $56.76
| Facility | | $35.85 | $51.72 | $56.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.62 / $7.63 / $8.40
| Professional | | $7.62 | $7.63 | $8.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.47 / $7.63 / $7.63
| Professional | | $2.47 | $7.63 | $7.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.72 / $3.72 / $3.72
| Professional | | $3.72 | $3.72 | $3.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.63 / $9.16 / $11.45
| Professional | | $7.63 | $9.16 | $11.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.35 / $7.63 / $11.45
| Professional | | $2.35 | $7.63 | $11.45 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.31 / $4.15 / $9.18
| Professional | | $2.31 | $4.15 | $9.18 |