- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.38 / $25.70 / $134.90
| Facility | | $21.38 | $25.70 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.50 / $22.39 / $28.18
| Professional | | $19.50 | $22.39 | $28.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.42 / $20.42 / $30.90
| Professional | | $20.42 | $20.42 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $57.54 / $63.10
| Professional | | $44.67 | $57.54 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.70 / $30.90 / $48.98
| Professional | | $25.70 | $30.90 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.96 / $36.31 / $50.12
| Professional | | $10.96 | $36.31 | $50.12 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.70 / $46.77 / $64.57
| Professional | | $25.70 | $46.77 | $64.57 |