- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Facility | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $81.28 / $102.33
| Professional | | $72.44 | $81.28 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $107.15 / $144.54
| Professional | | $107.15 | $107.15 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.50 / $107.15 / $128.82
| Professional | | $19.50 | $107.15 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Facility | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.23 / $107.15 / $537.03
| Professional | | $56.23 | $107.15 | $537.03 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $6,165.95 / $25,703.96
| Professional | | $75.86 | $6,165.95 | $25,703.96 |