- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $378.93 / $378.93 / $378.93
| Professional | | $378.93 | $378.93 | $378.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $599.41 / $599.41 / $599.41
| Facility | | $599.41 | $599.41 | $599.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $459.90 / $829.98 / $829.98
| Professional | | $459.90 | $829.98 | $829.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $754.53 / $790.08 / $790.08
| Professional | | $754.53 | $790.08 | $790.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $452.72 / $754.53 / $1,056.33
| Professional | | $452.72 | $754.53 | $1,056.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $462.98 / $599.41 / $829.98
| Professional | | $462.98 | $599.41 | $829.98 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $329.98 / $607.80 / $718.18
| Professional | | $329.98 | $607.80 | $718.18 |