- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.82 / $30.82 / $30.82
| Professional | | $30.82 | $30.82 | $30.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.13 / $50.13 / $50.13
| Facility | | $50.13 | $50.13 | $50.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.60 / $44.60 / $69.41
| Professional | | $44.60 | $44.60 | $69.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.10 / $66.06 / $66.06
| Professional | | $63.10 | $66.06 | $66.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.17 / $63.10 / $88.34
| Professional | | $44.17 | $63.10 | $88.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.60 / $50.13 / $69.41
| Professional | | $44.60 | $50.13 | $69.41 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.83 / $52.57 / $60.06
| Professional | | $50.83 | $52.57 | $60.06 |