- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $98.12 / $98.12 / $98.12
| Facility | | $98.12 | $98.12 | $98.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.54 / $65.00 / $121.77
| Professional | | $35.54 | $65.00 | $121.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.70 / $115.92 / $144.54
| Professional | | $110.70 | $115.92 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.84 / $99.63 / $154.97
| Professional | | $8.84 | $99.63 | $154.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.04 / $65.66 / $121.77
| Professional | | $39.04 | $65.66 | $121.77 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.68 / $90.60 / $104.91
| Professional | | $54.68 | $90.60 | $104.91 |