- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7.65 / $9.96 / $85.80
| Facility | | $7.65 | $9.96 | $85.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.18 / $2.25 / $9.80
| Professional | | $2.18 | $2.25 | $9.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.94 / $5.94 / $5.94
| Facility | | $5.94 | $5.94 | $5.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.18 / $2.18 / $2.18
| Professional | | $2.18 | $2.18 | $2.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.69 / $6.69 / $6.69
| Professional | | $6.69 | $6.69 | $6.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.40 / $2.62 / $3.05
| Professional | | $2.40 | $2.62 | $3.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.18 / $3.27 / $5.49
| Professional | | $2.18 | $3.27 | $5.49 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.20 / $2.88 / $5.65
| Professional | | $2.20 | $2.88 | $5.65 |