- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.89 / $21.89 / $21.89
| Professional | | $21.89 | $21.89 | $21.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.10 / $51.10 / $51.10
| Facility | | $51.10 | $51.10 | $51.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.78 / $70.76 / $70.76
| Professional | | $36.78 | $70.76 | $70.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.33 / $67.36 / $67.36
| Professional | | $64.33 | $67.36 | $67.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.60 / $64.33 / $90.06
| Professional | | $38.60 | $64.33 | $90.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.82 / $51.10 / $70.76
| Professional | | $44.82 | $51.10 | $70.76 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.82 / $53.60 / $61.23
| Professional | | $51.82 | $53.60 | $61.23 |