- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.39 / $23.39 / $23.39
| Professional | | $23.39 | $23.39 | $23.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58.50 / $58.50 / $58.50
| Facility | | $58.50 | $58.50 | $58.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.00 / $37.68 / $68.42
| Professional | | $31.00 | $37.68 | $68.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.20 / $65.13 / $81.26
| Professional | | $62.20 | $65.13 | $81.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.54 / $58.10 / $87.08
| Professional | | $43.54 | $58.10 | $87.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.05 / $41.85 / $68.42
| Professional | | $25.05 | $41.85 | $68.42 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.72 / $51.48 / $88.65
| Professional | | $40.72 | $51.48 | $88.65 |