- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.17 / $4.90 / $6.03
| Facility | | $4.17 | $4.90 | $6.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.00 / $3.98 / $3.98
| Professional | | $1.00 | $3.98 | $3.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.89 / $3.89 / $6.03
| Professional | | $3.89 | $3.89 | $6.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $162.18 / $173.78
| Professional | | $138.04 | $162.18 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.01 / $6.03 / $9.77
| Professional | | $5.01 | $6.03 | $9.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.09 / $6.76 / $9.55
| Professional | | $2.09 | $6.76 | $9.55 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.62 / $8.71 / $12.30
| Professional | | $5.62 | $8.71 | $12.30 |