- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.80 / $16.80 / $16.80
| Professional | | $16.80 | $16.80 | $16.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.20 / $39.20 / $39.20
| Facility | | $39.20 | $39.20 | $39.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.84 / $33.84 / $54.27
| Professional | | $33.84 | $33.84 | $54.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.34 / $51.66 / $51.66
| Professional | | $49.34 | $51.66 | $51.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.60 / $49.34 / $69.08
| Professional | | $29.60 | $49.34 | $69.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.45 / $39.20 / $54.27
| Professional | | $26.45 | $39.20 | $54.27 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.74 / $41.10 / $46.96
| Professional | | $39.74 | $41.10 | $46.96 |