- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.57 / $30.57 / $30.57
| Facility | | $30.57 | $30.57 | $30.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.30 / $30.30 / $42.33
| Professional | | $30.30 | $30.30 | $42.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.47 / $40.29 / $50.25
| Professional | | $38.47 | $40.29 | $50.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.94 / $34.63 / $53.87
| Professional | | $26.94 | $34.63 | $53.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.80 / $17.80 / $42.33
| Professional | | $17.80 | $17.80 | $42.33 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.48 / $33.50 / $38.47
| Professional | | $30.48 | $33.50 | $38.47 |