- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.33 / $196.33 / $196.33
| Professional | | $196.33 | $196.33 | $196.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $597.54 / $597.54 / $597.54
| Facility | | $597.54 | $597.54 | $597.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.86 / $360.86 / $827.40
| Professional | | $360.86 | $360.86 | $827.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $752.18 / $787.62 / $787.62
| Professional | | $752.18 | $787.62 | $787.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $451.31 / $752.18 / $1,053.05
| Professional | | $451.31 | $752.18 | $1,053.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.44 / $597.54 / $827.40
| Professional | | $330.44 | $597.54 | $827.40 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.96 / $605.91 / $715.94
| Professional | | $328.96 | $605.91 | $715.94 |