- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.70 / $120.92 / $155.19
| Facility | | $106.70 | $120.92 | $155.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.95 / $155.19 / $155.19
| Professional | | $55.95 | $155.19 | $155.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.56 / $168.25 / $196.88
| Professional | | $127.56 | $168.25 | $196.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.33 / $155.19 / $194.00
| Professional | | $129.33 | $155.19 | $194.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.32 / $155.19 / $194.00
| Professional | | $54.32 | $155.19 | $194.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.08 / $155.88 / $226.33
| Professional | | $115.08 | $155.88 | $226.33 |