- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,783.85 / $14,783.85 / $14,783.85
| Facility | | $14,783.85 | $14,783.85 | $14,783.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.76 / $25.77 / $35.38
| Professional | | $25.76 | $25.77 | $35.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.77 / $25.77 / $34.50
| Professional | | $25.77 | $25.77 | $34.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.58 / $33.58 / $33.58
| Professional | | $33.58 | $33.58 | $33.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.77 / $30.92 / $38.65
| Professional | | $25.77 | $30.92 | $38.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.48 / $27.32 / $38.65
| Professional | | $24.48 | $27.32 | $38.65 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.67 / $33.69 / $62.24
| Professional | | $29.67 | $33.69 | $62.24 |