- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $44.67 / $1,202.26
| Professional | | $30.20 | $44.67 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,148.15 / $2,089.30
| Professional | | $954.99 | $1,148.15 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $562.34 / $1,288.25
| Professional | | $389.05 | $562.34 | $1,288.25 |
- 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 |