- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.59 / $32.59 / $32.59
| Professional | | $32.59 | $32.59 | $32.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $76.04 / $76.04 / $76.04
| Facility | | $76.04 | $76.04 | $76.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.48 / $70.48 / $105.29
| Professional | | $70.48 | $70.48 | $105.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.72 / $100.23 / $100.23
| Professional | | $95.72 | $100.23 | $100.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.43 / $95.72 / $134.01
| Professional | | $57.43 | $95.72 | $134.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.10 / $76.04 / $105.29
| Professional | | $58.10 | $76.04 | $105.29 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.11 / $79.75 / $91.11
| Professional | | $77.11 | $79.75 | $91.11 |