- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.80 / $51.80 / $51.80
| Facility | | $51.80 | $51.80 | $51.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.81 / $51.81 / $51.81
| Facility | | $51.81 | $51.81 | $51.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.48 / $21.48 / $21.48
| Professional | | $21.48 | $21.48 | $21.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.01 / $35.01 / $35.01
| Professional | | $35.01 | $35.01 | $35.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.63 / $25.78 / $30.08
| Professional | | $23.63 | $25.78 | $30.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.48 / $28.77 / $32.22
| Professional | | $21.48 | $28.77 | $32.22 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.52 / $30.65 / $32.26
| Professional | | $24.52 | $30.65 | $32.26 |