- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $495.00 / $561.00 / $720.00
| Facility | | $495.00 | $561.00 | $720.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $453.93 / $453.93 / $453.93
| Professional | | $453.93 | $453.93 | $453.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $720.00 / $720.00 / $720.00
| Professional | | $720.00 | $720.00 | $720.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $570.38 / $683.92 / $832.20
| Professional | | $570.38 | $683.92 | $832.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.00 / $720.00 / $840.00
| Professional | | $660.00 | $720.00 | $840.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $600.70 / $720.00 / $900.00
| Professional | | $600.70 | $720.00 | $900.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $510.00 / $810.00 / $1,350.00
| Professional | | $510.00 | $810.00 | $1,350.00 |