- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.20 / $33.20 / $33.20
| Facility | | $33.20 | $33.20 | $33.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.28 / $27.37 / $45.62
| Professional | | $23.28 | $27.37 | $45.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.47 / $43.42 / $54.11
| Professional | | $41.47 | $43.42 | $54.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.01 / $37.32 / $58.06
| Professional | | $3.01 | $37.32 | $58.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.91 / $28.78 / $45.62
| Professional | | $16.91 | $28.78 | $45.62 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.91 / $34.27 / $39.28
| Professional | | $29.91 | $34.27 | $39.28 |