- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.94 / $25.94 / $25.94
| Facility | | $25.94 | $25.94 | $25.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.31 / $14.31 / $15.46
| Professional | | $14.31 | $14.31 | $15.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.31 / $14.31 / $16.76
| Professional | | $14.31 | $14.31 | $16.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.39 / $17.39 / $17.39
| Professional | | $17.39 | $17.39 | $17.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.31 / $17.17 / $21.47
| Professional | | $14.31 | $17.17 | $21.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.25 / $15.17 / $21.47
| Professional | | $14.25 | $15.17 | $21.47 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.15 / $16.46 / $18.02
| Professional | | $13.15 | $16.46 | $18.02 |