- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.32 / $30.32 / $30.32
| Facility | | $30.32 | $30.32 | $30.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.76 / $15.76 / $15.76
| Professional | | $15.76 | $15.76 | $15.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.32 / $30.32 / $30.32
| Facility | | $30.32 | $30.32 | $30.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.61 / $15.61 / $15.61
| Professional | | $15.61 | $15.61 | $15.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.78 / $22.78 / $22.78
| Professional | | $22.78 | $22.78 | $22.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.17 / $18.73 / $21.86
| Professional | | $17.17 | $18.73 | $21.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.61 / $18.72 / $23.42
| Professional | | $15.61 | $18.72 | $23.42 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.91 / $18.50 / $20.12
| Professional | | $14.91 | $18.50 | $20.12 |