- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30,720.00 / $30,720.00 / $30,720.00
| Facility | | $30,720.00 | $30,720.00 | $30,720.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.82 / $25.82 / $3,374.40
| Professional | | $25.82 | $25.82 | $3,374.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.11 / $31.11 / $31.11
| Professional | | $31.11 | $31.11 | $31.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.37 / $34.90 / $38.34
| Professional | | $30.37 | $34.90 | $38.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.58 / $56.58 / $56.58
| Professional | | $56.58 | $56.58 | $56.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.09 / $31.11 / $46.67
| Professional | | $29.09 | $31.11 | $46.67 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.24 / $37.24 / $38.79
| Professional | | $37.24 | $37.24 | $38.79 |