- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.79 / $21.52 / $1,285.93
| Facility | | $14.79 | $21.52 | $1,285.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.86 / $63.92 / $98.60
| Professional | | $35.86 | $63.92 | $98.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.13 / $21.52 / $21.52
| Professional | | $14.13 | $21.52 | $21.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.17 / $38.47 / $45.02
| Professional | | $29.17 | $38.47 | $45.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.93 / $21.52 / $26.90
| Professional | | $17.93 | $21.52 | $26.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.53 / $21.52 / $34.81
| Professional | | $7.53 | $21.52 | $34.81 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.07 / $32.58 / $45.11
| Professional | | $20.07 | $32.58 | $45.11 |