- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.82 / $27.82 / $27.82
| Professional | | $27.82 | $27.82 | $27.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $70.97 / $70.97 / $70.97
| Facility | | $70.97 | $70.97 | $70.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.26 / $98.27 / $98.27
| Professional | | $40.26 | $98.27 | $98.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.34 / $93.55 / $93.55
| Professional | | $89.34 | $93.55 | $93.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.69 / $89.34 / $125.08
| Professional | | $61.69 | $89.34 | $125.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.65 / $88.45 / $98.27
| Professional | | $34.65 | $88.45 | $98.27 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.98 / $74.43 / $85.04
| Professional | | $60.98 | $74.43 | $85.04 |