- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.55 / $30.55 / $30.55
| Professional | | $30.55 | $30.55 | $30.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $71.30 / $71.30 / $71.30
| Facility | | $71.30 | $71.30 | $71.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.32 / $51.32 / $98.73
| Professional | | $51.32 | $51.32 | $98.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.75 / $93.98 / $93.98
| Professional | | $89.75 | $93.98 | $93.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.85 / $89.75 / $125.65
| Professional | | $53.85 | $89.75 | $125.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.55 / $88.85 / $98.73
| Professional | | $62.55 | $88.85 | $98.73 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.30 / $74.78 / $85.43
| Professional | | $72.30 | $74.78 | $85.43 |