- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.35 / $33.35 / $33.35
| Professional | | $33.35 | $33.35 | $33.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $70.86 / $70.86 / $70.86
| Facility | | $70.86 | $70.86 | $70.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.87 / $98.11 / $98.11
| Professional | | $46.87 | $98.11 | $98.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.19 / $93.39 / $93.39
| Professional | | $89.19 | $93.39 | $93.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.43 / $89.19 / $124.87
| Professional | | $62.43 | $89.19 | $124.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.57 / $63.84 / $98.11
| Professional | | $37.57 | $63.84 | $98.11 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.90 / $74.31 / $84.89
| Professional | | $60.90 | $74.31 | $84.89 |