- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.51 / $24.38 / $31.28
| Facility | | $21.51 | $24.38 | $31.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.17 / $20.17 / $20.17
| Professional | | $20.17 | $20.17 | $20.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.61 / $31.28 / $31.28
| Professional | | $20.61 | $31.28 | $31.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.41 / $53.10 / $61.88
| Professional | | $42.41 | $53.10 | $61.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.68 / $31.28 / $36.50
| Professional | | $28.68 | $31.28 | $36.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.28 / $36.42 / $50.60
| Professional | | $31.28 | $36.42 | $50.60 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.20 / $47.35 / $65.56
| Professional | | $29.20 | $47.35 | $65.56 |