- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.10 / $387.28 / $900.90
| Facility | | $35.10 | $387.28 | $900.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.28 / $26.88 / $131.41
| Professional | | $0.28 | $26.88 | $131.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.27 / $0.27 / $0.33
| Professional | | $0.27 | $0.27 | $0.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.41 / $0.41 / $0.43
| Professional | | $0.41 | $0.41 | $0.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.28 / $0.33 / $0.39
| Professional | | $0.28 | $0.33 | $0.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.28 / $0.33 / $0.42
| Professional | | $0.28 | $0.33 | $0.42 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.33 / $0.46 / $0.51
| Professional | | $0.33 | $0.46 | $0.51 |