- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.30 / $16.30 / $16.30
| Professional | | $16.30 | $16.30 | $16.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38.02 / $38.02 / $38.02
| Facility | | $38.02 | $38.02 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.72 / $33.72 / $52.66
| Professional | | $33.72 | $33.72 | $52.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.87 / $50.13 / $50.13
| Professional | | $47.87 | $50.13 | $50.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.72 / $47.87 / $67.02
| Professional | | $28.72 | $47.87 | $67.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.36 / $38.02 / $52.66
| Professional | | $33.36 | $38.02 | $52.66 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.56 / $39.89 / $45.57
| Professional | | $38.56 | $39.89 | $45.57 |