- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $1,949.84
| Facility | | $1,949.84 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $44.67 / $1,949.84
| Professional | | $30.20 | $44.67 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,905.46 / $3,467.37
| Professional | | $1,584.89 | $1,905.46 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $912.01 / $2,089.30
| Professional | | $630.96 | $912.01 | $2,089.30 |
- 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 |