- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.80 / $36.79 / $1,058.27
| Facility | | $2.80 | $36.79 | $1,058.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.60 / $2.71 / $3.49
| Professional | | $2.60 | $2.71 | $3.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.36 / $3.59 / $3.59
| Professional | | $2.36 | $3.59 | $3.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.84 / $6.41 / $7.46
| Professional | | $4.84 | $6.41 | $7.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.99 / $3.59 / $4.49
| Professional | | $2.99 | $3.59 | $4.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.59 / $3.59 / $4.49
| Professional | | $3.59 | $3.59 | $4.49 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.35 / $5.42 / $7.51
| Professional | | $3.35 | $5.42 | $7.51 |