- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.22 / $149.22 / $149.22
| Professional | | $149.22 | $149.22 | $149.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $486.31 / $486.31 / $486.31
| Facility | | $486.31 | $486.31 | $486.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $312.30 / $312.30 / $563.04
| Professional | | $312.30 | $312.30 | $563.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $511.85 / $535.97 / $535.97
| Professional | | $511.85 | $535.97 | $535.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $358.30 / $511.85 / $716.59
| Professional | | $358.30 | $511.85 | $716.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.48 / $486.31 / $563.04
| Professional | | $75.48 | $486.31 | $563.04 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $459.20 / $470.22 / $493.12
| Professional | | $459.20 | $470.22 | $493.12 |