- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $568.88 / $568.88 / $568.88
| Facility | | $568.88 | $568.88 | $568.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.34 / $19.34 / $25.52
| Professional | | $19.34 | $19.34 | $25.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.59 / $18.59 / $18.59
| Professional | | $18.59 | $18.59 | $18.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.27 / $27.27 / $28.55
| Professional | | $27.27 | $27.27 | $28.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.45 / $22.31 / $26.03
| Professional | | $20.45 | $22.31 | $26.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.59 / $22.41 / $27.89
| Professional | | $18.59 | $22.41 | $27.89 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.38 / $18.72 / $26.30
| Professional | | $18.38 | $18.72 | $26.30 |