- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.30 / $19.30 / $19.30
| Professional | | $19.30 | $19.30 | $19.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.57 / $34.57 / $34.57
| Facility | | $34.57 | $34.57 | $34.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.14 / $31.98 / $49.79
| Professional | | $29.14 | $31.98 | $49.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.26 / $47.39 / $47.39
| Professional | | $45.26 | $47.39 | $47.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.54 / $45.26 / $63.36
| Professional | | $27.54 | $45.26 | $63.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.99 / $30.99 / $33.53
| Facility | | $30.99 | $30.99 | $33.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.54 / $34.57 / $49.79
| Professional | | $27.54 | $34.57 | $49.79 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.50 / $35.27 / $43.06
| Professional | | $24.50 | $35.27 | $43.06 |