- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $375.00 / $375.00
| Facility | | $375.00 | $375.00 | $375.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.50 / $42.00 / $375.00
| Professional | | $32.50 | $42.00 | $375.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.00 / $300.00 / $360.00
| Professional | | $220.00 | $300.00 | $360.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.32 / $175.00 / $328.00
| Professional | | $111.32 | $175.00 | $328.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.85 / $64.00 / $75.00
| Professional | | $34.85 | $64.00 | $75.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.69 / $49.30 / $71.83
| Professional | | $8.69 | $49.30 | $71.83 |