- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.38 / $20.38 / $20.38
| Professional | | $20.38 | $20.38 | $20.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.55 / $47.55 / $47.55
| Facility | | $47.55 | $47.55 | $47.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.72 / $36.72 / $65.81
| Professional | | $36.72 | $36.72 | $65.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.84 / $62.66 / $62.66
| Professional | | $59.84 | $62.66 | $62.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.90 / $59.84 / $83.78
| Professional | | $35.90 | $59.84 | $83.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.31 / $47.55 / $65.81
| Professional | | $36.31 | $47.55 | $65.81 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.21 / $49.86 / $56.96
| Professional | | $48.21 | $49.86 | $56.96 |