- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.10 / $25.05 / $32.15
| Facility | | $22.10 | $25.05 | $32.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.20 / $32.15 / $32.15
| Professional | | $21.20 | $32.15 | $32.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.54 / $57.43 / $67.25
| Professional | | $43.54 | $57.43 | $67.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.79 / $32.15 / $40.19
| Professional | | $26.79 | $32.15 | $40.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.25 / $32.15 / $52.00
| Professional | | $11.25 | $32.15 | $52.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $48.63 / $67.34
| Professional | | $30.00 | $48.63 | $67.34 |