- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.34 / $234.34 / $234.34
| Professional | | $234.34 | $234.34 | $234.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.56 / $489.56 / $489.56
| Facility | | $489.56 | $489.56 | $489.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.85 / $298.85 / $677.86
| Professional | | $298.85 | $298.85 | $677.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.24 / $645.28 / $645.28
| Professional | | $616.24 | $645.28 | $645.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $369.74 / $616.24 / $862.74
| Professional | | $369.74 | $616.24 | $862.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $365.68 / $489.56 / $677.86
| Professional | | $365.68 | $489.56 | $677.86 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.51 / $496.41 / $586.54
| Professional | | $269.51 | $496.41 | $586.54 |