- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.27 / $131.27 / $131.27
| Professional | | $131.27 | $131.27 | $131.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $560.41 / $560.41 / $560.41
| Facility | | $560.41 | $560.41 | $560.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.71 / $180.71 / $775.98
| Professional | | $180.71 | $180.71 | $775.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $705.44 / $738.68 / $738.68
| Professional | | $705.44 | $738.68 | $738.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $423.26 / $705.44 / $987.62
| Professional | | $423.26 | $705.44 | $987.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.42 / $698.39 / $775.98
| Professional | | $228.42 | $698.39 | $775.98 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.51 / $568.27 / $671.45
| Professional | | $308.51 | $568.27 | $671.45 |