- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.94 / $9.94 / $9.94
| Professional | | $9.94 | $9.94 | $9.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.44 / $27.44 / $27.44
| Facility | | $27.44 | $27.44 | $27.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.29 / $37.99 / $37.99
| Professional | | $16.29 | $37.99 | $37.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.54 / $36.17 / $36.17
| Professional | | $34.54 | $36.17 | $36.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.72 / $34.54 / $48.36
| Professional | | $20.72 | $34.54 | $48.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.82 / $27.44 / $43.08
| Professional | | $17.82 | $27.44 | $43.08 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.10 / $21.57 / $32.88
| Professional | | $15.10 | $21.57 | $32.88 |