- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.19 / $23.56 / $180.19
| Facility | | $16.19 | $23.56 | $180.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.79 / $17.79 / $26.95
| Professional | | $17.79 | $17.79 | $26.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.51 / $23.56 / $23.56
| Professional | | $15.51 | $23.56 | $23.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.13 / $35.45 / $42.31
| Professional | | $30.13 | $35.45 | $42.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.63 / $23.56 / $29.45
| Professional | | $19.63 | $23.56 | $29.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.24 / $23.56 / $38.10
| Professional | | $8.24 | $23.56 | $38.10 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.16 / $35.33 / $49.36
| Professional | | $23.16 | $35.33 | $49.36 |