- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,157.88 / $2,747.00 / $3,883.00
| Facility | | $1,157.88 | $2,747.00 | $3,883.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.62 / $448.65 / $2,002.00
| Professional | | $380.62 | $448.65 | $2,002.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $454.21 / $591.10 / $709.32
| Professional | | $454.21 | $591.10 | $709.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $606.53 / $681.46 / $3,857.00
| Professional | | $606.53 | $681.46 | $3,857.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.16 / $567.46 / $662.03
| Professional | | $520.16 | $567.46 | $662.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,689.00 / $1,689.00 / $1,689.00
| Facility | | $1,689.00 | $1,689.00 | $1,689.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $450.32 / $591.10 / $726.54
| Professional | | $450.32 | $591.10 | $726.54 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $462.37 / $2,000.00 / $5,304.00
| Professional | | $462.37 | $2,000.00 | $5,304.00 |