- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.65 / $42.29 / $55.82
| Professional | | $40.65 | $42.29 | $55.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $85.00 / $85.00 / $85.00
| Facility | | $85.00 | $85.00 | $85.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.65 / $40.65 / $49.93
| Professional | | $40.65 | $40.65 | $49.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.75 / $60.75 / $60.75
| Professional | | $60.75 | $60.75 | $60.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.72 / $48.78 / $56.91
| Professional | | $44.72 | $48.78 | $56.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.65 / $40.65 / $60.98
| Professional | | $25.65 | $40.65 | $60.98 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.52 / $40.92 / $53.68
| Professional | | $30.52 | $40.92 | $53.68 |