- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.06 / $36.06 / $36.06
| Professional | | $36.06 | $36.06 | $36.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $62.88 / $62.88 / $62.88
| Facility | | $62.88 | $62.88 | $62.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.48 / $61.48 / $87.08
| Professional | | $61.48 | $61.48 | $87.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.16 / $82.89 / $82.89
| Professional | | $79.16 | $82.89 | $82.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.50 / $79.16 / $110.82
| Professional | | $47.50 | $79.16 | $110.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.16 / $75.11 / $87.08
| Professional | | $55.16 | $75.11 | $87.08 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.61 / $63.76 / $75.34
| Professional | | $34.61 | $63.76 | $75.34 |