- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $675.00 / $675.00 / $675.00
| Facility | | $675.00 | $675.00 | $675.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.50 / $53.00 / $675.00
| Professional | | $32.50 | $53.00 | $675.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.00 / $600.00 / $720.00
| Professional | | $440.00 | $600.00 | $720.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.38 / $315.00 / $590.40
| Professional | | $200.38 | $315.00 | $590.40 |
- 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 |