- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.77 / $253.82 / $253.82
| Professional | | $165.77 | $253.82 | $253.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $230.27 / $230.27 / $230.27
| Facility | | $230.27 | $230.27 | $230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.00 / $175.00 / $318.85
| Professional | | $175.00 | $175.00 | $318.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.86 / $303.52 / $303.52
| Professional | | $289.86 | $303.52 | $303.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.92 / $289.86 / $405.80
| Professional | | $173.92 | $289.86 | $405.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.02 / $230.27 / $361.53
| Professional | | $202.02 | $230.27 | $361.53 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.02 / $241.50 / $275.89
| Professional | | $202.02 | $241.50 | $275.89 |