- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.45 / $40.61 / $40.61
| Professional | | $33.45 | $40.61 | $40.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.33 / $51.39 / $51.39
| Professional | | $40.33 | $51.39 | $51.39 |
- 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
- $40.31 / $66.11 / $72.22
| Professional | | $40.31 | $66.11 | $72.22 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $29.27 / $29.27
| Professional | | $29.27 | $29.27 | $29.27 |