- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.40 / $24.40 / $24.40
| Professional | | $24.40 | $24.40 | $24.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.30 / $64.30 / $64.30
| Facility | | $64.30 | $64.30 | $64.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.95 / $52.95 / $89.03
| Professional | | $52.95 | $52.95 | $89.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.94 / $84.75 / $84.75
| Professional | | $80.94 | $84.75 | $84.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.56 / $80.94 / $113.32
| Professional | | $48.56 | $80.94 | $113.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.88 / $80.13 / $89.03
| Professional | | $55.88 | $80.13 | $89.03 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.39 / $65.20 / $77.04
| Professional | | $35.39 | $65.20 | $77.04 |