- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.26 / $14.26 / $14.26
| Professional | | $14.26 | $14.26 | $14.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.26 / $33.26 / $33.26
| Facility | | $33.26 | $33.26 | $33.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.67 / $26.67 / $46.07
| Professional | | $26.67 | $26.67 | $46.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.88 / $43.85 / $43.85
| Professional | | $41.88 | $43.85 | $43.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.13 / $41.88 / $58.63
| Professional | | $25.13 | $41.88 | $58.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.18 / $33.26 / $46.07
| Professional | | $29.18 | $33.26 | $46.07 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.72 / $34.89 / $39.86
| Professional | | $33.72 | $34.89 | $39.86 |