- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $88.56 / $88.56 / $88.56
| Facility | | $88.56 | $88.56 | $88.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $88.55 / $88.55 / $88.55
| Facility | | $88.55 | $88.55 | $88.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.19 / $43.19 / $43.19
| Professional | | $43.19 | $43.19 | $43.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.33 / $63.33 / $74.73
| Professional | | $63.33 | $63.33 | $74.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.51 / $51.83 / $60.47
| Professional | | $47.51 | $51.83 | $60.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.19 / $52.06 / $64.79
| Professional | | $43.19 | $52.06 | $64.79 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.40 / $52.13 / $55.96
| Professional | | $44.40 | $52.13 | $55.96 |