- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.74 / $13.74 / $13.74
| Professional | | $13.74 | $13.74 | $13.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.06 / $32.06 / $32.06
| Facility | | $32.06 | $32.06 | $32.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.09 / $23.09 / $44.39
| Professional | | $23.09 | $23.09 | $44.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.35 / $42.25 / $42.25
| Professional | | $40.35 | $42.25 | $42.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.21 / $40.35 / $56.49
| Professional | | $24.21 | $40.35 | $56.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.13 / $32.06 / $44.39
| Professional | | $28.13 | $32.06 | $44.39 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.97 / $33.61 / $38.40
| Professional | | $26.97 | $33.61 | $38.40 |