- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.88 / $27.88 / $27.88
| Facility | | $27.88 | $27.88 | $27.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.72 / $24.18 / $38.31
| Professional | | $20.72 | $24.18 | $38.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.83 / $36.47 / $45.45
| Professional | | $34.83 | $36.47 | $45.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.49 / $31.35 / $48.76
| Professional | | $2.49 | $31.35 | $48.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.92 / $25.46 / $38.31
| Professional | | $14.92 | $25.46 | $38.31 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.67 / $28.79 / $32.99
| Professional | | $28.67 | $28.79 | $32.99 |