- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.93 / $282.93 / $282.93
| Professional | | $282.93 | $282.93 | $282.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $567.07 / $567.07 / $567.07
| Facility | | $567.07 | $567.07 | $567.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $496.34 / $785.21 / $785.21
| Professional | | $496.34 | $785.21 | $785.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $713.83 / $747.47 / $747.47
| Professional | | $713.83 | $747.47 | $747.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $428.30 / $713.83 / $999.36
| Professional | | $428.30 | $713.83 | $999.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $497.47 / $706.69 / $785.21
| Professional | | $497.47 | $706.69 | $785.21 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $312.18 / $575.01 / $679.43
| Professional | | $312.18 | $575.01 | $679.43 |