- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.77 / $12.13 / $12.13
| Professional | | $9.77 | $12.13 | $12.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.74 / $15.23 / $15.23
| Professional | | $11.74 | $15.23 | $15.23 |
- 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
- $11.76 / $19.34 / $20.98
| Professional | | $11.76 | $19.34 | $20.98 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $29.27 / $29.27
| Professional | | $29.27 | $29.27 | $29.27 |