- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $68.02 / $68.02 / $68.02
| Facility | | $68.02 | $68.02 | $68.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $68.01 / $68.01 / $68.01
| Facility | | $68.01 | $68.01 | $68.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.27 / $25.27 / $25.27
| Professional | | $25.27 | $25.27 | $25.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.50 / $44.50 / $44.50
| Professional | | $44.50 | $44.50 | $44.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.79 / $30.32 / $35.38
| Professional | | $27.79 | $30.32 | $35.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.27 / $36.57 / $37.90
| Professional | | $25.27 | $36.57 | $37.90 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.66 / $34.26 / $45.46
| Professional | | $16.66 | $34.26 | $45.46 |