- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24.36 / $27.61 / $35.44
| Facility | | $24.36 | $27.61 | $35.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.65 / $15.65 / $29.53
| Professional | | $15.65 | $15.65 | $29.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.36 / $35.44 / $35.44
| Professional | | $23.36 | $35.44 | $35.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.02 / $63.34 / $74.11
| Professional | | $48.02 | $63.34 | $74.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.53 / $35.44 / $44.30
| Professional | | $29.53 | $35.44 | $44.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.40 / $35.44 / $57.33
| Professional | | $12.40 | $35.44 | $57.33 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.07 / $53.64 / $74.27
| Professional | | $33.07 | $53.64 | $74.27 |