- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.04 / $30.04 / $30.04
| Professional | | $30.04 | $30.04 | $30.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $63.66 / $63.66 / $63.66
| Facility | | $63.66 | $63.66 | $63.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.94 / $44.94 / $88.12
| Professional | | $44.94 | $44.94 | $88.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.11 / $83.88 / $83.88
| Professional | | $80.11 | $83.88 | $83.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.07 / $80.11 / $112.15
| Professional | | $48.07 | $80.11 | $112.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.14 / $63.66 / $99.93
| Professional | | $41.14 | $63.66 | $99.93 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.06 / $64.55 / $76.25
| Professional | | $35.06 | $64.55 | $76.25 |