- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.85 / $19.85 / $19.85
| Professional | | $19.85 | $19.85 | $19.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $46.31 / $46.31 / $46.31
| Facility | | $46.31 | $46.31 | $46.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.35 / $64.12 / $64.12
| Professional | | $33.35 | $64.12 | $64.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.29 / $61.04 / $61.04
| Professional | | $58.29 | $61.04 | $61.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.97 / $58.29 / $81.61
| Professional | | $34.97 | $58.29 | $81.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.61 / $46.31 / $64.12
| Professional | | $40.61 | $46.31 | $64.12 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.95 / $48.56 / $55.48
| Professional | | $46.95 | $48.56 | $55.48 |