- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.65 / $44.47 / $44.47
| Professional | | $36.65 | $44.47 | $44.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.15 / $56.20 / $56.20
| Professional | | $44.15 | $56.20 | $56.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,078.00 / $1,078.00 / $1,078.00
| Facility | | $1,078.00 | $1,078.00 | $1,078.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.16 / $72.31 / $78.66
| Professional | | $44.16 | $72.31 | $78.66 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $29.27 / $29.27
| Professional | | $29.27 | $29.27 | $29.27 |