- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.82 / $22.82 / $22.82
| Facility | | $22.82 | $22.82 | $22.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.77 / $22.57 / $31.60
| Professional | | $18.77 | $22.57 | $31.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.73 / $30.08 / $37.47
| Professional | | $28.73 | $30.08 | $37.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.10 / $25.85 / $40.21
| Professional | | $20.10 | $25.85 | $40.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.26 / $22.82 / $31.60
| Professional | | $13.26 | $22.82 | $31.60 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.74 / $23.73 / $28.73
| Professional | | $22.74 | $23.73 | $28.73 |