- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.51 / $227.51 / $227.51
| Professional | | $227.51 | $227.51 | $227.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $506.84 / $506.84 / $506.84
| Facility | | $506.84 | $506.84 | $506.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $409.07 / $409.07 / $409.07
| Professional | | $409.07 | $409.07 | $409.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $506.84 / $530.72 / $530.72
| Professional | | $506.84 | $530.72 | $530.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.38 / $444.63 / $506.84
| Professional | | $153.38 | $444.63 | $506.84 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.60 / $398.60 / $398.60
| Professional | | $398.60 | $398.60 | $398.60 |