- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.34 / $39.34 / $39.34
| Professional | | $39.34 | $39.34 | $39.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.66 / $54.66 / $54.66
| Facility | | $54.66 | $54.66 | $54.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.35 / $39.35 / $75.66
| Professional | | $39.35 | $39.35 | $75.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.78 / $72.02 / $72.02
| Professional | | $68.78 | $72.02 | $72.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.27 / $68.78 / $96.29
| Professional | | $41.27 | $68.78 | $96.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.96 / $54.66 / $75.66
| Professional | | $47.96 | $54.66 | $75.66 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.42 / $57.31 / $65.47
| Professional | | $55.42 | $57.31 | $65.47 |