- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $41.92 / $41.92 / $41.92
| Facility | | $41.92 | $41.92 | $41.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.44 / $42.16 / $58.05
| Professional | | $24.44 | $42.16 | $58.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.77 / $55.26 / $70.02
| Professional | | $52.77 | $55.26 | $70.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.94 / $47.49 / $73.88
| Professional | | $36.94 | $47.49 | $73.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.64 / $41.92 / $58.05
| Professional | | $24.64 | $41.92 | $58.05 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.18 / $44.36 / $46.68
| Professional | | $44.18 | $44.36 | $46.68 |