- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38.21 / $43.30 / $55.57
| Facility | | $38.21 | $43.30 | $55.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.89 / $55.57 / $55.57
| Professional | | $26.89 | $55.57 | $55.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.16 / $61.36 / $73.25
| Professional | | $52.16 | $61.36 | $73.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.31 / $55.57 / $69.47
| Professional | | $46.31 | $55.57 | $69.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.45 / $55.57 / $69.47
| Professional | | $19.45 | $55.57 | $69.47 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.36 / $63.56 / $104.20
| Professional | | $39.36 | $63.56 | $104.20 |