- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $210.42 / $238.47 / $306.06
| Facility | | $210.42 | $238.47 | $306.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.00 / $200.00 / $200.00
| Professional | | $200.00 | $200.00 | $200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.06 / $306.06 / $306.06
| Professional | | $306.06 | $306.06 | $306.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.08 / $274.43 / $327.60
| Professional | | $262.08 | $274.43 | $327.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.56 / $306.06 / $357.07
| Professional | | $280.56 | $306.06 | $357.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.14 / $306.06 / $382.58
| Professional | | $212.14 | $306.06 | $382.58 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.29 / $374.92 / $573.86
| Professional | | $286.29 | $374.92 | $573.86 |