- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.82 / $32.82 / $32.82
| Facility | | $32.82 | $32.82 | $32.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.96 / $20.17 / $9,600.00
| Professional | | $19.96 | $20.17 | $9,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.97 / $19.97 / $19.97
| Professional | | $19.97 | $19.97 | $19.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.21 / $28.21 / $28.21
| Professional | | $28.21 | $28.21 | $28.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.97 / $23.97 / $27.96
| Professional | | $21.97 | $23.97 | $27.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.97 / $23.19 / $29.96
| Professional | | $19.97 | $23.19 | $29.96 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.89 / $21.79 / $24.92
| Professional | | $16.89 | $21.79 | $24.92 |