- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.60 / $14.60 / $14.60
| Facility | | $14.60 | $14.60 | $14.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.07 / $4.11 / $11.30
| Professional | | $4.07 | $4.11 | $11.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.72 / $68.00 / $107.04
| Professional | | $7.72 | $68.00 | $107.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.78 / $5.76 / $6.88
| Professional | | $4.78 | $5.76 | $6.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.23 / $19.23 / $19.23
| Professional | | $19.23 | $19.23 | $19.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.21 / $5.85 / $10.43
| Professional | | $4.21 | $5.85 | $10.43 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.00 / $15.68 / $257.50
| Professional | | $3.00 | $15.68 | $257.50 |