- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.09 / $20.09 / $20.09
| Professional | | $20.09 | $20.09 | $20.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $48.08 / $48.08 / $48.08
| Facility | | $48.08 | $48.08 | $48.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.34 / $36.34 / $66.58
| Professional | | $36.34 | $36.34 | $66.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.53 / $63.38 / $63.38
| Professional | | $60.53 | $63.38 | $63.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.32 / $60.53 / $84.74
| Professional | | $36.32 | $60.53 | $84.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.70 / $48.08 / $66.58
| Professional | | $27.70 | $48.08 | $66.58 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.32 / $50.43 / $57.61
| Professional | | $41.32 | $50.43 | $57.61 |