- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,747.00 / $2,747.00 / $2,747.00
| Facility | | $2,747.00 | $2,747.00 | $2,747.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.92 / $10.94 / $24.18
| Professional | | $6.92 | $10.94 | $24.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.27 / $18.71 / $22.46
| Professional | | $15.27 | $18.71 | $22.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.70 / $14.63 / $34.58
| Professional | | $11.70 | $14.63 | $34.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.46 / $16.47 / $19.46
| Professional | | $8.46 | $16.47 | $19.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,078.00 / $1,078.00 / $1,078.00
| Facility | | $1,078.00 | $1,078.00 | $1,078.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.27 / $18.71 / $36.64
| Professional | | $15.27 | $18.71 | $36.64 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.60 / $12.98 / $27.18
| Professional | | $6.60 | $12.98 | $27.18 |