- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $450.00 / $450.00 / $450.00
| Facility | | $450.00 | $450.00 | $450.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.50 / $53.00 / $450.00
| Professional | | $32.50 | $53.00 | $450.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.00 / $375.00 / $450.00
| Professional | | $275.00 | $375.00 | $450.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.58 / $210.00 / $393.60
| Professional | | $133.58 | $210.00 | $393.60 |
- 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 |