- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.40 / $309.42 / $579.70
| Facility | | $158.40 | $309.42 | $579.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.04 / $17.04 / $17.04
| Professional | | $17.04 | $17.04 | $17.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.99 / $25.99 / $25.99
| Professional | | $25.99 | $25.99 | $25.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.00 / $32.44 / $39.88
| Professional | | $29.00 | $32.44 | $39.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.30 / $16.39 / $18.23
| Professional | | $16.30 | $16.39 | $18.23 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.27 / $117.27 / $128.66
| Professional | | $117.27 | $117.27 | $128.66 |