- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $48.52 / $48.52 / $48.52
| Facility | | $48.52 | $48.52 | $48.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.65 / $42.06 / $67.19
| Professional | | $36.65 | $42.06 | $67.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.08 / $63.96 / $79.76
| Professional | | $61.08 | $63.96 | $79.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.36 / $54.97 / $85.51
| Professional | | $4.36 | $54.97 | $85.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.87 / $44.48 / $67.19
| Professional | | $25.87 | $44.48 | $67.19 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.69 / $50.52 / $61.08
| Professional | | $41.69 | $50.52 | $61.08 |