- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24.10 / $24.10 / $24.10
| Facility | | $24.10 | $24.10 | $24.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.32 / $12.32 / $12.43
| Professional | | $12.32 | $12.32 | $12.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.32 / $12.32 / $12.32
| Professional | | $12.32 | $12.32 | $12.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.93 / $17.93 / $17.93
| Professional | | $17.93 | $17.93 | $17.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.55 / $14.78 / $17.25
| Professional | | $13.55 | $14.78 | $17.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.32 / $14.73 / $18.48
| Professional | | $12.32 | $14.73 | $18.48 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.99 / $14.68 / $15.84
| Professional | | $11.99 | $14.68 | $15.84 |