- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $42.12 / $42.12 / $42.12
| Facility | | $42.12 | $42.12 | $42.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.60 / $32.47 / $6,033.73
| Professional | | $24.60 | $32.47 | $6,033.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.65 / $23.65 / $23.65
| Professional | | $23.65 | $23.65 | $23.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.83 / $33.83 / $39.92
| Professional | | $33.83 | $33.83 | $39.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.01 / $28.38 / $33.11
| Professional | | $26.01 | $28.38 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.65 / $27.81 / $35.47
| Professional | | $23.65 | $27.81 | $35.47 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.56 / $27.35 / $29.89
| Professional | | $21.56 | $27.35 | $29.89 |