- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.20 / $36.31 / $43.65
| Facility | | $30.20 | $36.31 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.18 / $34.67 / $52.48
| Professional | | $28.18 | $34.67 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.65 / $43.65 / $44.67
| Professional | | $43.65 | $43.65 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $125.89 / $138.04
| Professional | | $97.72 | $125.89 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.31 / $43.65 / $54.95
| Professional | | $36.31 | $43.65 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.49 / $54.95 / $109.65
| Professional | | $15.49 | $54.95 | $109.65 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.74 / $87.10 / $141.25
| Professional | | $40.74 | $87.10 | $141.25 |