- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $524.81 / $524.81
| Facility | | $524.81 | $524.81 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $44.67 / $524.81
| Professional | | $30.20 | $44.67 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $457.09 / $831.76
| Professional | | $380.19 | $457.09 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $245.47 / $562.34
| Professional | | $169.82 | $245.47 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $64.57 / $81.28
| Professional | | $34.67 | $64.57 | $81.28 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.71 / $48.98 / $72.44
| Professional | | $8.71 | $48.98 | $72.44 |