- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.60 / $236.60 / $236.60
| Professional | | $236.60 | $236.60 | $236.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $395.65 / $395.65 / $395.65
| Facility | | $395.65 | $395.65 | $395.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $296.00 / $296.00 / $547.86
| Professional | | $296.00 | $296.00 | $547.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $498.05 / $521.52 / $521.52
| Professional | | $498.05 | $521.52 | $521.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $348.64 / $498.05 / $697.27
| Professional | | $348.64 | $498.05 | $697.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.08 / $395.65 / $547.86
| Professional | | $289.08 | $395.65 | $547.86 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.81 / $401.20 / $474.05
| Professional | | $217.81 | $401.20 | $474.05 |