- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $302.00 / $302.00
| Facility | | $302.00 | $302.00 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $44.67 / $302.00
| Professional | | $30.20 | $44.67 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $229.09 / $416.87
| Professional | | $190.55 | $229.09 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $141.25 / $316.23
| Professional | | $97.72 | $141.25 | $316.23 |
- 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 |