- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.09 / $16.64 / $727.01
| Facility | | $5.09 | $16.64 | $727.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.07 / $8.50 / $10.91
| Professional | | $3.07 | $8.50 | $10.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.91 / $10.91 / $10.91
| Professional | | $10.91 | $10.91 | $10.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.62 / $8.97 / $10.71
| Professional | | $7.62 | $8.97 | $10.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.09 / $10.91 / $12.73
| Professional | | $9.09 | $10.91 | $12.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.00 / $4.50 / $10.91
| Professional | | $3.00 | $4.50 | $10.91 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.37 / $7.28 / $10.88
| Professional | | $1.37 | $7.28 | $10.88 |