- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.17 / $24.97 / $211.91
| Facility | | $17.17 | $24.97 | $211.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.87 / $24.07 / $35.00
| Professional | | $18.87 | $24.07 | $35.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.48 / $24.97 / $24.97
| Professional | | $16.48 | $24.97 | $24.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.83 / $44.62 / $52.25
| Professional | | $33.83 | $44.62 | $52.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.81 / $24.97 / $29.13
| Professional | | $20.81 | $24.97 | $29.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.74 / $24.97 / $40.40
| Professional | | $8.74 | $24.97 | $40.40 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.31 / $37.79 / $52.33
| Professional | | $23.31 | $37.79 | $52.33 |