- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.21 / $20.65 / $263.44
| Facility | | $17.21 | $20.65 | $263.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.92 / $18.75 / $42.77
| Professional | | $17.92 | $18.75 | $42.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.48 / $25.03 / $25.03
| Professional | | $16.48 | $25.03 | $25.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.93 / $44.75 / $52.36
| Professional | | $33.93 | $44.75 | $52.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.86 / $25.03 / $31.29
| Professional | | $20.86 | $25.03 | $31.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.76 / $25.03 / $40.50
| Professional | | $8.76 | $25.03 | $40.50 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.86 / $37.60 / $52.47
| Professional | | $20.86 | $37.60 | $52.47 |