- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.12 / $326.12 / $326.12
| Professional | | $326.12 | $326.12 | $326.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.17 / $508.17 / $508.17
| Facility | | $508.17 | $508.17 | $508.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.41 / $703.64 / $703.64
| Professional | | $530.41 | $703.64 | $703.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $639.66 / $669.81 / $669.81
| Professional | | $639.66 | $669.81 | $669.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $383.80 / $639.66 / $895.54
| Professional | | $383.80 | $639.66 | $895.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $445.79 / $598.09 / $703.64
| Professional | | $445.79 | $598.09 | $703.64 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $279.75 / $515.29 / $608.85
| Professional | | $279.75 | $515.29 | $608.85 |