- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $70.04 / $70.04 / $70.04
| Facility | | $70.04 | $70.04 | $70.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.08 / $1,743.10 / $9,969.29
| Professional | | $31.08 | $1,743.10 | $9,969.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $70.04 / $70.04 / $70.04
| Facility | | $70.04 | $70.04 | $70.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.09 / $31.09 / $31.09
| Professional | | $31.09 | $31.09 | $31.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.45 / $57.17 / $109.98
| Professional | | $48.45 | $57.17 | $109.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.20 / $37.31 / $43.53
| Professional | | $34.20 | $37.31 | $43.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.09 / $36.63 / $46.64
| Professional | | $31.09 | $36.63 | $46.64 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.63 / $39.38 / $107.26
| Professional | | $29.63 | $39.38 | $107.26 |