- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $65.14 / $65.14 / $65.14
| Facility | | $65.14 | $65.14 | $65.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.50 / $30.61 / $32.90
| Professional | | $29.50 | $30.61 | $32.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $65.15 / $65.15 / $65.15
| Facility | | $65.15 | $65.15 | $65.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.35 / $31.35 / $37.61
| Professional | | $31.35 | $31.35 | $37.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.06 / $40.06 / $40.06
| Professional | | $40.06 | $40.06 | $40.06 |
- 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
- $30.73 / $32.47 / $46.10
| Professional | | $30.73 | $32.47 | $46.10 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.98 / $37.79 / $43.02
| Professional | | $17.98 | $37.79 | $43.02 |