- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.66 / $28.66 / $28.66
| Professional | | $28.66 | $28.66 | $28.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.53 / $56.53 / $56.53
| Facility | | $56.53 | $56.53 | $56.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.73 / $48.73 / $78.27
| Professional | | $48.73 | $48.73 | $78.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.15 / $74.50 / $74.50
| Professional | | $71.15 | $74.50 | $74.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.69 / $71.15 / $99.61
| Professional | | $42.69 | $71.15 | $99.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.69 / $64.84 / $78.27
| Professional | | $45.69 | $64.84 | $78.27 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.12 / $57.31 / $67.72
| Professional | | $31.12 | $57.31 | $67.72 |