- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.94 / $107.94 / $107.94
| Professional | | $107.94 | $107.94 | $107.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $739.28 / $739.28 / $739.28
| Facility | | $739.28 | $739.28 | $739.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.09 / $205.09 / $1,023.65
| Professional | | $205.09 | $205.09 | $1,023.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.59 / $974.44 / $974.44
| Professional | | $930.59 | $974.44 | $974.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $558.35 / $930.59 / $1,302.83
| Professional | | $558.35 | $930.59 | $1,302.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.05 / $739.28 / $1,023.65
| Professional | | $242.05 | $739.28 | $1,023.65 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $406.98 / $749.63 / $885.75
| Professional | | $406.98 | $749.63 | $885.75 |