- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.71 / $11.71 / $11.71
| Professional | | $11.71 | $11.71 | $11.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.32 / $27.32 / $27.32
| Facility | | $27.32 | $27.32 | $27.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.27 / $24.27 / $37.84
| Professional | | $24.27 | $24.27 | $37.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.40 / $36.02 / $36.02
| Professional | | $34.40 | $36.02 | $36.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.64 / $34.40 / $48.16
| Professional | | $20.64 | $34.40 | $48.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.97 / $27.32 / $42.90
| Professional | | $23.97 | $27.32 | $42.90 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.98 / $28.66 / $32.74
| Professional | | $22.98 | $28.66 | $32.74 |