- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.60 / $16.60 / $16.60
| Professional | | $16.60 | $16.60 | $16.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $48.15 / $48.15 / $48.15
| Facility | | $48.15 | $48.15 | $48.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.27 / $29.34 / $55.12
| Professional | | $24.27 | $29.34 | $55.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.51 / $50.11 / $52.47
| Professional | | $45.51 | $50.11 | $52.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.08 / $45.10 / $70.15
| Professional | | $35.08 | $45.10 | $70.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.59 / $19.48 / $25.96
| Facility | | $2.59 | $19.48 | $25.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.89 / $33.43 / $55.12
| Professional | | $19.89 | $33.43 | $55.12 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.33 / $46.26 / $66.09
| Professional | | $41.33 | $46.26 | $66.09 |