- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.14 / $18.20 / $123.03
| Facility | | $15.14 | $18.20 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.13 / $16.60 / $22.39
| Professional | | $14.13 | $16.60 | $22.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.79 / $14.79 / $14.79
| Professional | | $14.79 | $14.79 | $14.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.62 / $40.74 / $45.71
| Professional | | $31.62 | $40.74 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.62 / $22.39 / $31.62
| Professional | | $18.62 | $22.39 | $31.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.76 / $25.70 / $27.54
| Professional | | $7.76 | $25.70 | $27.54 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.92 / $32.36 / $37.15
| Professional | | $26.92 | $32.36 | $37.15 |