- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $481.47 / $481.47 / $500.92
| Professional | | $481.47 | $481.47 | $500.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $716.77 / $716.77 / $716.77
| Facility | | $716.77 | $716.77 | $716.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $544.74 / $544.74 / $992.51
| Professional | | $544.74 | $544.74 | $992.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.28 / $944.80 / $944.80
| Professional | | $902.28 | $944.80 | $944.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $541.37 / $902.28 / $1,263.19
| Professional | | $541.37 | $902.28 | $1,263.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $533.24 / $716.77 / $992.51
| Professional | | $533.24 | $716.77 | $992.51 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $394.59 / $726.81 / $858.80
| Professional | | $394.59 | $726.81 | $858.80 |