- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $240.30 / $240.30 / $240.30
| Facility | | $240.30 | $240.30 | $240.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.85 / $18.85 / $18.85
| Professional | | $18.85 | $18.85 | $18.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.56 / $12.56 / $12.56
| Professional | | $12.56 | $12.56 | $12.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.36 / $42.88 / $50.20
| Professional | | $33.36 | $42.88 | $50.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.21 / $12.21 / $56.36
| Professional | | $12.21 | $12.21 | $56.36 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.25 / $13.19 / $16.48
| Professional | | $8.25 | $13.19 | $16.48 |