- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.32 / $32.32 / $32.32
| Facility | | $32.32 | $32.32 | $32.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.07 / $18.80 / $6,516.00
| Professional | | $18.07 | $18.80 | $6,516.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.07 / $18.07 / $18.07
| Professional | | $18.07 | $18.07 | $18.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.93 / $25.93 / $25.93
| Professional | | $25.93 | $25.93 | $25.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.89 / $21.69 / $25.31
| Professional | | $19.89 | $21.69 | $25.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.07 / $21.32 / $27.12
| Professional | | $18.07 | $21.32 | $27.12 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.32 / $20.39 / $22.91
| Professional | | $16.32 | $20.39 | $22.91 |