- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $8,511.38 / $8,511.38
| Facility | | $2,818.38 | $8,511.38 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $1,071.52 / $2,137.96
| Professional | | $288.40 | $1,071.52 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $1,621.81 / $1,737.80
| Professional | | $363.08 | $1,621.81 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $588.84 / $9,549.93
| Professional | | $467.74 | $588.84 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $1,445.44 / $1,819.70
| Professional | | $275.42 | $1,445.44 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,019.95
| Facility | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $1,412.54 / $2,089.30
| Professional | | $371.54 | $1,412.54 | $2,089.30 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $3,235.94 / $5,370.32
| Professional | | $338.84 | $3,235.94 | $5,370.32 |