- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.30 / $5.17 / $29.43
| Facility | | $4.30 | $5.17 | $29.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.92 / $112.75 / $223.86
| Professional | | $18.92 | $112.75 | $223.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.12 / $6.26 / $6.26
| Professional | | $4.12 | $6.26 | $6.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.48 / $11.19 / $13.14
| Professional | | $8.48 | $11.19 | $13.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.22 / $6.26 / $7.83
| Professional | | $5.22 | $6.26 | $7.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.19 / $6.26 / $10.13
| Professional | | $2.19 | $6.26 | $10.13 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.22 / $9.49 / $13.14
| Professional | | $5.22 | $9.49 | $13.14 |