- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.23 / $21.23 / $21.23
| Professional | | $21.23 | $21.23 | $21.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.28 / $64.28 / $64.28
| Facility | | $64.28 | $64.28 | $64.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.77 / $89.00 / $89.00
| Professional | | $40.77 | $89.00 | $89.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.91 / $84.72 / $84.72
| Professional | | $80.91 | $84.72 | $84.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.55 / $80.91 / $113.27
| Professional | | $48.55 | $80.91 | $113.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.53 / $64.28 / $89.00
| Professional | | $36.53 | $64.28 | $89.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.38 / $65.18 / $77.01
| Professional | | $35.38 | $65.18 | $77.01 |