- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.44 / $155.44 / $155.44
| Professional | | $155.44 | $155.44 | $155.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $571.64 / $571.64 / $571.64
| Facility | | $571.64 | $571.64 | $571.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.77 / $293.77 / $791.56
| Professional | | $293.77 | $293.77 | $791.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $719.60 / $753.51 / $753.51
| Professional | | $719.60 | $753.51 | $753.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $431.76 / $719.60 / $1,007.44
| Professional | | $431.76 | $719.60 | $1,007.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $351.72 / $571.64 / $791.56
| Professional | | $351.72 | $571.64 | $791.56 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.69 / $579.65 / $684.92
| Professional | | $314.69 | $579.65 | $684.92 |