- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.86 / $47.06 / $47.06
| Professional | | $38.86 | $47.06 | $47.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.87 / $59.39 / $59.39
| Professional | | $46.87 | $59.39 | $59.39 |
- 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
- $46.61 / $76.62 / $83.59
| Professional | | $46.61 | $76.62 | $83.59 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $29.27 / $29.27
| Professional | | $29.27 | $29.27 | $29.27 |