- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.96 / $49.60 / $309.43
| Facility | | $2.96 | $49.60 | $309.43 |
- 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
- $9.89 / $13.05 / $15.27
| Professional | | $9.89 | $13.05 | $15.27 |
- 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
- $1.26 / $3.59 / $5.80
| Professional | | $1.26 | $3.59 | $5.80 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.35 / $6.55 / $13.91
| Professional | | $3.35 | $6.55 | $13.91 |