- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.05 / $33.53 / $317.72
| Facility | | $23.05 | $33.53 | $317.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.64 / $25.34 / $87.75
| Professional | | $24.64 | $25.34 | $87.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.18 / $33.53 / $33.53
| Professional | | $22.18 | $33.53 | $33.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.42 / $59.91 / $70.13
| Professional | | $45.42 | $59.91 | $70.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.94 / $33.53 / $41.91
| Professional | | $27.94 | $33.53 | $41.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.73 / $33.53 / $54.24
| Professional | | $11.73 | $33.53 | $54.24 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.75 / $50.36 / $70.27
| Professional | | $23.75 | $50.36 | $70.27 |