- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.38 / $11.38 / $11.38
| Professional | | $11.38 | $11.38 | $11.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.70 / $23.70 / $23.70
| Facility | | $23.70 | $23.70 | $23.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.88 / $18.85 / $31.16
| Professional | | $15.88 | $18.85 | $31.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.33 / $29.66 / $36.97
| Professional | | $28.33 | $29.66 | $36.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.14 / $28.25 / $39.65
| Professional | | $2.14 | $28.25 | $39.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.36 / $21.54 / $31.16
| Professional | | $12.36 | $21.54 | $31.16 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.33 / $26.84 / $45.42
| Professional | | $23.33 | $26.84 | $45.42 |