- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $446.68 / $446.68
| Facility | | $446.68 | $446.68 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $44.67 / $446.68
| Professional | | $30.20 | $44.67 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $398.11 / $1,621.81
| Professional | | $316.23 | $398.11 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $208.93 / $478.63
| Professional | | $147.91 | $208.93 | $478.63 |
- 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 |