- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $63.06 / $63.06 / $63.06
| Facility | | $63.06 | $63.06 | $63.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.14 / $32.15 / $34.72
| Professional | | $32.14 | $32.15 | $34.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.15 / $32.15 / $38.94
| Professional | | $32.15 | $32.15 | $38.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.40 / $40.40 / $40.40
| Professional | | $40.40 | $40.40 | $40.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.15 / $38.58 / $48.22
| Professional | | $32.15 | $38.58 | $48.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.15 / $33.10 / $48.23
| Professional | | $32.15 | $33.10 | $48.23 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.52 / $39.26 / $41.86
| Professional | | $31.52 | $39.26 | $41.86 |