- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.76 / $20.12 / $251.25
| Facility | | $16.76 | $20.12 | $251.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.46 / $17.46 / $17.46
| Professional | | $17.46 | $17.46 | $17.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.10 / $24.38 / $24.38
| Professional | | $16.10 | $24.38 | $24.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.03 / $43.57 / $51.00
| Professional | | $33.03 | $43.57 | $51.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.32 / $24.38 / $30.48
| Professional | | $20.32 | $24.38 | $30.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.52 / $24.38 / $39.44
| Professional | | $8.52 | $24.38 | $39.44 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.76 / $36.90 / $51.10
| Professional | | $22.76 | $36.90 | $51.10 |