- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.08 / $64.08 / $64.08
| Facility | | $64.08 | $64.08 | $64.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.28 / $36.64 / $49.82
| Professional | | $36.28 | $36.64 | $49.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.28 / $36.28 / $42.53
| Professional | | $36.28 | $36.28 | $42.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.71 / $44.12 / $50.74
| Professional | | $39.71 | $44.12 | $50.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.28 / $43.53 / $54.41
| Professional | | $36.28 | $43.53 | $54.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.15 / $38.27 / $54.42
| Professional | | $36.15 | $38.27 | $54.42 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.26 / $40.72 / $45.72
| Professional | | $31.26 | $40.72 | $45.72 |