- 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 / $289.25 / $450.00
| Professional | | $32.50 | $289.25 | $450.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.85 / $373.55 / $450.00
| Professional | | $245.85 | $373.55 | $450.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.39 / $365.18 / $435.94
| Professional | | $310.39 | $365.18 | $435.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.72 / $300.00 / $478.38
| Professional | | $145.72 | $300.00 | $478.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.77 / $314.36 / $314.36
| Professional | | $235.77 | $314.36 | $314.36 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.46 / $27.44 / $27.92
| Professional | | $20.46 | $27.44 | $27.92 |