- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,200.00 / $1,200.00 / $1,200.00
| Facility | | $1,200.00 | $1,200.00 | $1,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.50 / $53.00 / $1,200.00
| Professional | | $32.50 | $53.00 | $1,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $825.00 / $1,125.00 / $1,350.00
| Professional | | $825.00 | $1,125.00 | $1,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.22 / $560.00 / $1,049.59
| Professional | | $356.22 | $560.00 | $1,049.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $64.00 / $77.00
| Professional | | $30.00 | $64.00 | $77.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.69 / $49.30 / $71.83
| Professional | | $8.69 | $49.30 | $71.83 |