- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.33 / $123.78 / $209.95
| Facility | | $15.33 | $123.78 | $209.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.36 / $16.84 / $46.80
| Professional | | $16.36 | $16.84 | $46.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.72 / $14.72 / $14.72
| Professional | | $14.72 | $14.72 | $14.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $39.84 / $46.63
| Professional | | $30.20 | $39.84 | $46.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.57 / $22.30 / $27.87
| Professional | | $18.57 | $22.30 | $27.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.80 / $22.30 / $36.07
| Professional | | $7.80 | $22.30 | $36.07 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.27 / $32.11 / $36.93
| Professional | | $27.27 | $32.11 | $36.93 |