- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.99 / $24.92 / $31.98
| Facility | | $21.99 | $24.92 | $31.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.43 / $31.98 / $31.98
| Professional | | $19.43 | $31.98 | $31.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.01 / $52.77 / $61.77
| Professional | | $40.01 | $52.77 | $61.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.65 / $31.98 / $39.97
| Professional | | $26.65 | $31.98 | $39.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.19 / $31.98 / $47.75
| Professional | | $11.19 | $31.98 | $47.75 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.85 / $44.67 / $61.85
| Professional | | $29.85 | $44.67 | $61.85 |