- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.97 / $25.97 / $25.97
| Professional | | $25.97 | $25.97 | $25.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $60.59 / $60.59 / $60.59
| Facility | | $60.59 | $60.59 | $60.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.62 / $43.62 / $83.91
| Professional | | $43.62 | $43.62 | $83.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.28 / $79.87 / $79.87
| Professional | | $76.28 | $79.87 | $79.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.77 / $76.28 / $106.79
| Professional | | $45.77 | $76.28 | $106.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.15 / $60.59 / $83.91
| Professional | | $53.15 | $60.59 | $83.91 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.44 / $63.55 / $72.59
| Professional | | $61.44 | $63.55 | $72.59 |