- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.28 / $15.28 / $15.28
| Professional | | $15.28 | $15.28 | $15.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.65 / $35.65 / $35.65
| Facility | | $35.65 | $35.65 | $35.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.10 / $27.10 / $49.37
| Professional | | $27.10 | $27.10 | $49.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.88 / $46.99 / $46.99
| Professional | | $44.88 | $46.99 | $46.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.93 / $44.88 / $62.83
| Professional | | $26.93 | $44.88 | $62.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.27 / $35.65 / $55.98
| Professional | | $31.27 | $35.65 | $55.98 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.99 / $36.15 / $42.72
| Professional | | $20.99 | $36.15 | $42.72 |