- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.90 / $186.90 / $186.90
| Professional | | $186.90 | $186.90 | $186.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $247.62 / $247.62 / $247.62
| Facility | | $247.62 | $247.62 | $247.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.05 / $248.05 / $342.88
| Professional | | $248.05 | $248.05 | $342.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.70 / $326.39 / $326.39
| Professional | | $311.70 | $326.39 | $326.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.03 / $311.70 / $436.39
| Professional | | $187.03 | $311.70 | $436.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.22 / $291.45 / $342.88
| Professional | | $217.22 | $291.45 | $342.88 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.30 / $251.09 / $296.69
| Professional | | $136.30 | $251.09 | $296.69 |