- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.29 / $113.29 / $113.29
| Professional | | $113.29 | $113.29 | $113.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.45 / $323.45 / $323.45
| Facility | | $323.45 | $323.45 | $323.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.61 / $185.61 / $447.90
| Professional | | $185.61 | $185.61 | $447.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.18 / $426.37 / $426.37
| Professional | | $407.18 | $426.37 | $426.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.31 / $407.18 / $570.04
| Professional | | $244.31 | $407.18 | $570.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.97 / $323.45 / $447.90
| Professional | | $169.97 | $323.45 | $447.90 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.07 / $328.00 / $387.56
| Professional | | $178.07 | $328.00 | $387.56 |