- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.16 / $34.18 / $43.87
| Facility | | $30.16 | $34.18 | $43.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.87 / $43.87 / $44.76
| Professional | | $43.87 | $43.87 | $44.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.79 / $121.07 / $141.72
| Professional | | $91.79 | $121.07 | $141.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.56 / $43.87 / $54.84
| Professional | | $36.56 | $43.87 | $54.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.36 / $43.87 / $109.60
| Professional | | $15.36 | $43.87 | $109.60 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.95 / $97.54 / $141.97
| Professional | | $40.95 | $97.54 | $141.97 |