- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.36 / $33.36 / $33.36
| Professional | | $33.36 | $33.36 | $33.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.05 / $64.05 / $64.05
| Facility | | $64.05 | $64.05 | $64.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.36 / $50.36 / $88.69
| Professional | | $50.36 | $50.36 | $88.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.63 / $84.43 / $84.43
| Professional | | $80.63 | $84.43 | $84.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.38 / $80.63 / $112.88
| Professional | | $48.38 | $80.63 | $112.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.11 / $64.73 / $88.69
| Professional | | $46.11 | $64.73 | $88.69 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.25 / $64.95 / $76.73
| Professional | | $35.25 | $64.95 | $76.73 |