- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.14 / $31.14 / $31.14
| Professional | | $31.14 | $31.14 | $31.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $61.93 / $61.93 / $61.93
| Facility | | $61.93 | $61.93 | $61.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.05 / $45.05 / $85.75
| Professional | | $45.05 | $45.05 | $85.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.95 / $81.62 / $81.62
| Professional | | $77.95 | $81.62 | $81.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.77 / $77.95 / $109.13
| Professional | | $46.77 | $77.95 | $109.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.79 / $61.93 / $85.75
| Professional | | $38.79 | $61.93 | $85.75 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.22 / $64.94 / $74.19
| Professional | | $53.22 | $64.94 | $74.19 |