- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $600.00 / $600.00 / $600.00
| Facility | | $600.00 | $600.00 | $600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.50 / $42.00 / $600.00
| Professional | | $32.50 | $42.00 | $600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $385.00 / $525.00 / $630.00
| Professional | | $385.00 | $525.00 | $630.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.11 / $280.00 / $524.79
| Professional | | $178.11 | $280.00 | $524.79 |
- 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 |