- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.18 / $26.61 / $106.20
| Facility | | $22.18 | $26.61 | $106.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.98 / $23.98 / $23.98
| Professional | | $23.98 | $23.98 | $23.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.90 / $32.26 / $32.26
| Professional | | $15.90 | $32.26 | $32.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.61 / $40.83 / $47.58
| Professional | | $32.61 | $40.83 | $47.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.57 / $32.26 / $37.63
| Professional | | $29.57 | $32.26 | $37.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.02 / $32.26 / $40.32
| Professional | | $28.02 | $32.26 | $40.32 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.42 / $36.92 / $51.84
| Professional | | $29.42 | $36.92 | $51.84 |