- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.69 / $33.69 / $33.69
| Professional | | $33.69 | $33.69 | $33.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $65.15 / $65.15 / $65.15
| Facility | | $65.15 | $65.15 | $65.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.38 / $51.23 / $69.68
| Professional | | $43.38 | $51.23 | $69.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.92 / $64.19 / $76.63
| Professional | | $55.92 | $64.19 | $76.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.03 / $48.04 / $56.04
| Professional | | $44.03 | $48.04 | $56.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.84 / $50.50 / $65.81
| Professional | | $39.84 | $50.50 | $65.81 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.11 / $36.71 / $50.97
| Professional | | $30.11 | $36.71 | $50.97 |