- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.69 / $50.69 / $50.69
| Facility | | $50.69 | $50.69 | $50.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.36 / $48.45 / $69.20
| Professional | | $40.36 | $48.45 | $69.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.92 / $65.88 / $81.86
| Professional | | $62.92 | $65.88 | $81.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.91 / $56.46 / $87.82
| Professional | | $43.91 | $56.46 | $87.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.73 / $50.69 / $69.20
| Professional | | $28.73 | $50.69 | $69.20 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.54 / $51.85 / $62.92
| Professional | | $50.54 | $51.85 | $62.92 |