- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.63 / $27.63 / $27.63
| Professional | | $27.63 | $27.63 | $27.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $44.93 / $44.93 / $44.93
| Facility | | $44.93 | $44.93 | $44.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.97 / $39.97 / $62.22
| Professional | | $39.97 | $39.97 | $62.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.56 / $59.23 / $59.23
| Professional | | $56.56 | $59.23 | $59.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.59 / $56.56 / $79.18
| Professional | | $39.59 | $56.56 | $79.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.40 / $44.93 / $62.22
| Professional | | $34.40 | $44.93 | $62.22 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.56 / $47.12 / $53.83
| Professional | | $45.56 | $47.12 | $53.83 |