- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.70 / $256.70 / $256.70
| Professional | | $256.70 | $256.70 | $256.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $654.84 / $654.84 / $654.84
| Facility | | $654.84 | $654.84 | $654.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $555.76 / $555.76 / $906.72
| Professional | | $555.76 | $555.76 | $906.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $824.29 / $863.13 / $863.13
| Professional | | $824.29 | $863.13 | $863.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $494.57 / $824.29 / $1,154.01
| Professional | | $494.57 | $824.29 | $1,154.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $533.29 / $654.84 / $906.72
| Professional | | $533.29 | $654.84 | $906.72 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.50 / $664.01 / $784.57
| Professional | | $360.50 | $664.01 | $784.57 |