- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $974.28 / $974.28 / $974.28
| Facility | | $974.28 | $974.28 | $974.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.68 / $450.00 / $856.04
| Professional | | $97.68 | $450.00 | $856.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,357.75 / $3,357.75 / $3,515.97
| Professional | | $3,357.75 | $3,357.75 | $3,515.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.95 / $182.95 / $182.95
| Professional | | $182.95 | $182.95 | $182.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.34 / $974.28 / $998.24
| Professional | | $530.34 | $974.28 | $998.24 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,268.50 / $2,268.50 / $2,268.50
| Professional | | $2,268.50 | $2,268.50 | $2,268.50 |