- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.27 / $185.27 / $185.27
| Professional | | $185.27 | $185.27 | $185.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.03 / $436.03 / $436.03
| Facility | | $436.03 | $436.03 | $436.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.77 / $311.77 / $603.75
| Professional | | $311.77 | $311.77 | $603.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $548.86 / $574.72 / $574.72
| Professional | | $548.86 | $574.72 | $574.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $329.32 / $548.86 / $768.40
| Professional | | $329.32 | $548.86 | $768.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $333.13 / $436.03 / $603.75
| Professional | | $333.13 | $436.03 | $603.75 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.04 / $442.14 / $522.41
| Professional | | $240.04 | $442.14 | $522.41 |