- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $825.00 / $825.00 / $825.00
| Facility | | $825.00 | $825.00 | $825.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.50 / $53.00 / $825.00
| Professional | | $32.50 | $53.00 | $825.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $550.00 / $750.00 / $900.00
| Professional | | $550.00 | $750.00 | $900.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.90 / $385.00 / $721.60
| Professional | | $244.90 | $385.00 | $721.60 |
- 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 |