- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38.01 / $43.08 / $55.28
| Facility | | $38.01 | $43.08 | $55.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.51 / $55.28 / $55.28
| Professional | | $36.51 | $55.28 | $55.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.93 / $98.82 / $115.64
| Professional | | $74.93 | $98.82 | $115.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.07 / $55.28 / $69.11
| Professional | | $46.07 | $55.28 | $69.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.35 / $55.28 / $89.43
| Professional | | $19.35 | $55.28 | $89.43 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.60 / $83.69 / $115.88
| Professional | | $51.60 | $83.69 | $115.88 |