- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58.62 / $58.62 / $58.62
| Facility | | $58.62 | $58.62 | $58.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.53 / $3,667.86 / $18,720.00
| Professional | | $32.53 | $3,667.86 | $18,720.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.27 / $31.27 / $31.27
| Professional | | $31.27 | $31.27 | $31.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.81 / $44.81 / $44.81
| Professional | | $44.81 | $44.81 | $44.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.40 / $37.52 / $43.78
| Professional | | $34.40 | $37.52 | $43.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.27 / $36.82 / $46.91
| Professional | | $31.27 | $36.82 | $46.91 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.50 / $35.50 / $38.25
| Professional | | $29.50 | $35.50 | $38.25 |