- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $525.00 / $525.00 / $525.00
| Facility | | $525.00 | $525.00 | $525.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.50 / $53.00 / $525.00
| Professional | | $32.50 | $53.00 | $525.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.00 / $450.00 / $540.00
| Professional | | $330.00 | $450.00 | $540.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.85 / $245.00 / $459.20
| Professional | | $155.85 | $245.00 | $459.20 |
- 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 |