- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.18 / $125.18 / $125.18
| Professional | | $125.18 | $125.18 | $125.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.46 / $239.45 / $299.17
| Professional | | $160.46 | $239.45 | $299.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.55 / $315.36 / $386.72
| Professional | | $140.55 | $315.36 | $386.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.69 / $212.84 / $248.32
| Professional | | $182.69 | $212.84 | $248.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.45 / $308.42 / $314.02
| Professional | | $239.45 | $308.42 | $314.02 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.58 / $312.67 / $520.99
| Professional | | $219.58 | $312.67 | $520.99 |