- 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
- $340.08 / $340.08 / $340.08
| Professional | | $340.08 | $340.08 | $340.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $425.52 / $425.52 / $558.90
| Professional | | $425.52 | $425.52 | $558.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.84 / $417.10 / $10,901.00
| Professional | | $95.84 | $417.10 | $10,901.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,028.00 / $3,028.00 / $3,028.00
| Facility | | $3,028.00 | $3,028.00 | $3,028.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.41 / $511.00 / $624.20
| Professional | | $228.41 | $511.00 | $624.20 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $317.20 / $4,824.31 / $23,625.00
| Professional | | $317.20 | $4,824.31 | $23,625.00 |