- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $371.54
| Facility | | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $44.67 / $371.54
| Professional | | $30.20 | $44.67 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $309.03 / $562.34
| Professional | | $257.04 | $309.03 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $173.78 / $398.11
| Professional | | $123.03 | $173.78 | $398.11 |
- 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 |