- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,921.84 / $15,921.84 / $15,921.84
| Facility | | $15,921.84 | $15,921.84 | $15,921.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.28 / $60.89 / $17,235.62
| Professional | | $60.28 | $60.89 | $17,235.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.10 / $109.10 / $109.10
| Facility | | $109.10 | $109.10 | $109.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.76 / $60.29 / $69.12
| Professional | | $58.76 | $60.29 | $69.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.70 / $71.70 / $71.70
| Professional | | $71.70 | $71.70 | $71.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.29 / $72.34 / $90.44
| Professional | | $60.29 | $72.34 | $90.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.76 / $63.91 / $90.44
| Professional | | $58.76 | $63.91 | $90.44 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.91 / $59.84 / $74.30
| Professional | | $53.91 | $59.84 | $74.30 |