- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.72 / $37.72 / $37.72
| Professional | | $37.72 | $37.72 | $37.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $72.45 / $72.45 / $72.45
| Facility | | $72.45 | $72.45 | $72.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.84 / $58.84 / $100.34
| Professional | | $58.84 | $58.84 | $100.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.22 / $95.52 / $95.52
| Professional | | $91.22 | $95.52 | $95.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.73 / $91.22 / $127.71
| Professional | | $54.73 | $91.22 | $127.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.56 / $78.30 / $100.34
| Professional | | $63.56 | $78.30 | $100.34 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.89 / $73.47 / $86.82
| Professional | | $39.89 | $73.47 | $86.82 |