- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $81.59 / $81.59 / $320.39
| Facility | | $81.59 | $81.59 | $320.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.07 / $26.07 / $26.07
| Professional | | $26.07 | $26.07 | $26.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.92 / $14.92 / $14.92
| Professional | | $14.92 | $14.92 | $14.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.52 / $42.88 / $50.20
| Professional | | $32.52 | $42.88 | $50.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.93 / $30.93 / $46.40
| Professional | | $30.93 | $30.93 | $46.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.49 / $14.49 / $66.89
| Professional | | $14.49 | $14.49 | $66.89 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.25 / $13.19 / $16.48
| Professional | | $8.25 | $13.19 | $16.48 |