- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.84 / $39.84 / $39.84
| Professional | | $39.84 | $39.84 | $39.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $92.97 / $92.97 / $92.97
| Facility | | $92.97 | $92.97 | $92.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.70 / $128.74 / $128.74
| Professional | | $75.70 | $128.74 | $128.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.04 / $122.55 / $122.55
| Professional | | $117.04 | $122.55 | $122.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.22 / $117.04 / $163.86
| Professional | | $70.22 | $117.04 | $163.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.41 / $115.87 / $128.74
| Professional | | $80.41 | $115.87 | $128.74 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.56 / $97.51 / $111.40
| Professional | | $81.56 | $97.51 | $111.40 |