- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.83 / $224.83 / $224.83
| Professional | | $224.83 | $224.83 | $224.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $486.01 / $486.01 / $486.01
| Facility | | $486.01 | $486.01 | $486.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $405.51 / $405.51 / $672.98
| Professional | | $405.51 | $405.51 | $672.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $611.79 / $640.63 / $640.63
| Professional | | $611.79 | $640.63 | $640.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $367.08 / $611.79 / $856.52
| Professional | | $367.08 | $611.79 | $856.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.37 / $605.67 / $672.98
| Professional | | $426.37 | $605.67 | $672.98 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $492.82 / $509.71 / $582.32
| Professional | | $492.82 | $509.71 | $582.32 |