- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.05 / $30.20 / $51.29
| Professional | | $19.05 | $30.20 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.88 / $30.20 / $41.69
| Professional | | $21.88 | $30.20 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.29 / $58.88 / $72.44
| Professional | | $51.29 | $58.88 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.38 / $30.90 / $39.81
| Professional | | $17.38 | $30.90 | $39.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.22 / $32.36 / $61.66
| Professional | | $16.22 | $32.36 | $61.66 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.98 / $29.51 / $63.10
| Professional | | $16.98 | $29.51 | $63.10 |