- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.74 / $25.74 / $25.74
| Professional | | $25.74 | $25.74 | $25.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $70.19 / $70.19 / $70.19
| Facility | | $70.19 | $70.19 | $70.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.20 / $65.20 / $97.20
| Professional | | $65.20 | $65.20 | $97.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.36 / $92.52 / $92.52
| Professional | | $88.36 | $92.52 | $92.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.02 / $88.36 / $123.70
| Professional | | $53.02 | $88.36 | $123.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.71 / $70.19 / $97.20
| Professional | | $59.71 | $70.19 | $97.20 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.65 / $71.17 / $84.10
| Professional | | $38.65 | $71.17 | $84.10 |