- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.15 / $56.32 / $56.32
| Professional | | $26.15 | $56.32 | $56.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29.76 / $29.76 / $29.76
| Facility | | $29.76 | $29.76 | $29.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.81 / $36.93 / $44.31
| Professional | | $23.81 | $36.93 | $44.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.70 / $31.12 / $32.59
| Professional | | $27.70 | $31.12 | $32.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.49 / $35.45 / $41.36
| Professional | | $32.49 | $35.45 | $41.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.90 / $36.76 / $40.61
| Professional | | $20.90 | $36.76 | $40.61 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.13 / $27.13 / $27.86
| Professional | | $27.13 | $27.13 | $27.86 |