- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.31 / $14.31 / $14.31
| Professional | | $14.31 | $14.31 | $14.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.84 / $56.84 / $56.84
| Facility | | $56.84 | $56.84 | $56.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.10 / $23.10 / $78.72
| Professional | | $23.10 | $23.10 | $78.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.56 / $74.93 / $74.93
| Professional | | $71.56 | $74.93 | $74.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.94 / $71.56 / $100.18
| Professional | | $42.94 | $71.56 | $100.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.26 / $56.84 / $78.72
| Professional | | $27.26 | $56.84 | $78.72 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.28 / $57.64 / $68.11
| Professional | | $31.28 | $57.64 | $68.11 |