- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.11 / $34.11 / $34.11
| Professional | | $34.11 | $34.11 | $34.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $79.63 / $79.63 / $79.63
| Facility | | $79.63 | $79.63 | $79.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.32 / $110.28 / $110.28
| Professional | | $57.32 | $110.28 | $110.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.25 / $104.97 / $104.97
| Professional | | $100.25 | $104.97 | $104.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.15 / $100.25 / $140.35
| Professional | | $60.15 | $100.25 | $140.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.83 / $79.63 / $110.28
| Professional | | $60.83 | $79.63 | $110.28 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.75 / $83.52 / $95.42
| Professional | | $80.75 | $83.52 | $95.42 |