- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $676.08
| Facility | | $676.08 | $676.08 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $44.67 / $676.08
| Professional | | $30.20 | $44.67 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $616.60 / $1,122.02
| Professional | | $512.86 | $616.60 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $316.23 / $724.44
| Professional | | $218.78 | $316.23 | $724.44 |
- 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 |