- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.14 / $21.77 / $263.44
| Facility | | $18.14 | $21.77 | $263.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.03 / $19.03 / $19.03
| Professional | | $19.03 | $19.03 | $19.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.47 / $26.39 / $26.39
| Professional | | $17.47 | $26.39 | $26.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.77 / $47.18 / $55.21
| Professional | | $35.77 | $47.18 | $55.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.99 / $26.39 / $32.99
| Professional | | $21.99 | $26.39 | $32.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.24 / $26.39 / $42.69
| Professional | | $9.24 | $26.39 | $42.69 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.99 / $39.64 / $55.31
| Professional | | $21.99 | $39.64 | $55.31 |