- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $98.94 / $98.94 / $98.94
| Facility | | $98.94 | $98.94 | $98.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.07 / $58.33 / $6,035.70
| Professional | | $56.07 | $58.33 | $6,035.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $98.94 / $98.94 / $98.94
| Facility | | $98.94 | $98.94 | $98.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.07 / $56.07 / $56.07
| Professional | | $56.07 | $56.07 | $56.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.17 / $80.17 / $80.17
| Professional | | $80.17 | $80.17 | $80.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.67 / $67.28 / $78.50
| Professional | | $61.67 | $67.28 | $78.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.07 / $65.89 / $84.11
| Professional | | $56.07 | $65.89 | $84.11 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.67 / $54.59 / $70.83
| Professional | | $42.67 | $54.59 | $70.83 |