- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.10 / $21.39 / $89.13
| Facility | | $2.10 | $21.39 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.93 / $2.00 / $13.70
| Professional | | $1.93 | $2.00 | $13.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.77 / $1.77 / $1.77
| Professional | | $1.77 | $1.77 | $1.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.67 / $4.84 / $5.63
| Professional | | $3.67 | $4.84 | $5.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.25 / $2.70 / $3.38
| Professional | | $2.25 | $2.70 | $3.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.35 / $2.70 / $4.36
| Professional | | $1.35 | $2.70 | $4.36 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.30 / $3.88 / $4.45
| Professional | | $3.30 | $3.88 | $4.45 |