- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.52 / $54.52 / $54.52
| Facility | | $54.52 | $54.52 | $54.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.29 / $29.59 / $40.22
| Professional | | $29.29 | $29.59 | $40.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.29 / $29.29 / $33.85
| Professional | | $29.29 | $29.29 | $33.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.11 / $35.11 / $35.11
| Professional | | $35.11 | $35.11 | $35.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.29 / $35.15 / $43.94
| Professional | | $29.29 | $35.15 | $43.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.77 / $29.29 / $43.94
| Professional | | $28.77 | $29.29 | $43.94 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.23 / $34.04 / $36.39
| Professional | | $27.23 | $34.04 | $36.39 |