- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.29 / $30.97 / $133.47
| Facility | | $21.29 | $30.97 | $133.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.36 / $22.35 / $30.97
| Professional | | $19.36 | $22.35 | $30.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.42 / $30.97 / $30.97
| Professional | | $20.42 | $30.97 | $30.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.99 / $55.38 / $64.80
| Professional | | $41.99 | $55.38 | $64.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.81 / $30.97 / $38.72
| Professional | | $25.81 | $30.97 | $38.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.84 / $30.97 / $50.12
| Professional | | $10.84 | $30.97 | $50.12 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.81 / $46.54 / $64.94
| Professional | | $25.81 | $46.54 | $64.94 |