- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.14 / $47.14 / $47.14
| Facility | | $47.14 | $47.14 | $47.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.46 / $37.85 / $40.28
| Professional | | $31.46 | $37.85 | $40.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.52 / $38.76 / $40.28
| Professional | | $31.52 | $38.76 | $40.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.34 / $49.34 / $49.34
| Professional | | $49.34 | $49.34 | $49.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.00 / $5.00 / $670.00
| Professional | | $5.00 | $5.00 | $670.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.47 / $38.00 / $57.00
| Professional | | $27.47 | $38.00 | $57.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.29 / $34.11 / $48.74
| Professional | | $27.29 | $34.11 | $48.74 |