- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $144.54 / $199.53
| Professional | | $114.82 | $144.54 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $173.78 / $302.00
| Professional | | $128.82 | $173.78 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $173.78 / $199.53
| Professional | | $147.91 | $173.78 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $194.98 / $239.88
| Professional | | $162.18 | $194.98 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $162.18 / $245.47
| Professional | | $114.82 | $162.18 | $245.47 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $181.97 / $389.05
| Professional | | $134.90 | $181.97 | $389.05 |