- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.84 / $26.10 / $50.00
| Facility | | $2.84 | $26.10 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.06 / $2.37 / $5.43
| Professional | | $2.06 | $2.37 | $5.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.96 / $1.96 / $1.96
| Professional | | $1.96 | $1.96 | $1.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.86 / $5.09 / $5.94
| Professional | | $3.86 | $5.09 | $5.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.37 / $2.84 / $3.50
| Professional | | $2.37 | $2.84 | $3.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.42 / $2.84 / $4.59
| Professional | | $1.42 | $2.84 | $4.59 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.60 / $4.09 / $4.70
| Professional | | $3.60 | $4.09 | $4.70 |