- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.77 / $22.52 / $117.68
| Facility | | $18.77 | $22.52 | $117.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.19 / $23.98 / $31.24
| Professional | | $23.19 | $23.98 | $31.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.90 / $27.30 / $27.30
| Professional | | $15.90 | $27.30 | $27.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.60 / $40.83 / $47.58
| Professional | | $34.60 | $40.83 | $47.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.03 / $27.30 / $31.85
| Professional | | $25.03 | $27.30 | $31.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.30 / $28.02 / $38.93
| Professional | | $27.30 | $28.02 | $38.93 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.48 / $36.43 / $51.19
| Professional | | $25.48 | $36.43 | $51.19 |