- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $144.54 / $190.55
| Professional | | $109.65 | $144.54 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $199.53 / $245.47
| Professional | | $144.54 | $199.53 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $245.47 / $281.84
| Professional | | $234.42 | $245.47 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $173.78 / $229.09
| Professional | | $114.82 | $173.78 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $173.78 / $208.93
| Professional | | $128.82 | $173.78 | $208.93 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $109.65 / $151.36
| Professional | | $109.65 | $109.65 | $151.36 |