- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.17 / $236.17 / $236.17
| Professional | | $236.17 | $236.17 | $236.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.98 / $549.98 / $549.98
| Facility | | $549.98 | $549.98 | $549.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $365.10 / $365.10 / $761.54
| Professional | | $365.10 | $365.10 | $761.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $692.31 / $724.93 / $724.93
| Professional | | $692.31 | $724.93 | $724.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $415.39 / $692.31 / $969.23
| Professional | | $415.39 | $692.31 | $969.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $334.32 / $549.98 / $761.54
| Professional | | $334.32 | $549.98 | $761.54 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.77 / $557.67 / $658.95
| Professional | | $302.77 | $557.67 | $658.95 |