- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.96 / $25.96 / $25.96
| Professional | | $25.96 | $25.96 | $25.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.11 / $56.11 / $56.11
| Facility | | $56.11 | $56.11 | $56.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.82 / $46.82 / $77.70
| Professional | | $46.82 | $46.82 | $77.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.64 / $73.97 / $73.97
| Professional | | $70.64 | $73.97 | $73.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.45 / $70.64 / $98.90
| Professional | | $49.45 | $70.64 | $98.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.22 / $56.11 / $77.70
| Professional | | $49.22 | $56.11 | $77.70 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.89 / $50.00 / $67.23
| Professional | | $30.89 | $50.00 | $67.23 |