- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.46 / $12.46 / $12.46
| Professional | | $12.46 | $12.46 | $12.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.04 / $32.04 / $32.04
| Facility | | $32.04 | $32.04 | $32.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.14 / $18.14 / $44.37
| Professional | | $18.14 | $18.14 | $44.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.34 / $42.24 / $42.24
| Professional | | $40.34 | $42.24 | $42.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.24 / $40.34 / $56.48
| Professional | | $28.24 | $40.34 | $56.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.61 / $32.04 / $44.37
| Professional | | $15.61 | $32.04 | $44.37 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.55 / $33.61 / $38.39
| Professional | | $27.55 | $33.61 | $38.39 |