- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.97 / $74.70 / $277.42
| Facility | | $47.97 | $74.70 | $277.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.47 / $56.44 / $77.00
| Professional | | $38.47 | $56.44 | $77.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.82 / $30.82 / $30.82
| Professional | | $30.82 | $30.82 | $30.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.24 / $113.00 / $125.00
| Professional | | $94.24 | $113.00 | $125.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.44 / $61.57 / $71.83
| Professional | | $56.44 | $61.57 | $71.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.33 / $76.97 / $95.00
| Professional | | $51.33 | $76.97 | $95.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.31 / $84.69 / $125.76
| Professional | | $51.31 | $84.69 | $125.76 |