- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $602.56
| Facility | | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $44.67 / $602.56
| Professional | | $30.20 | $44.67 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $537.03 / $977.24
| Professional | | $446.68 | $537.03 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $281.84 / $630.96
| Professional | | $194.98 | $281.84 | $630.96 |
- 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 |