- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,528.00 / $6,084.00 / $7,424.00
| Facility | | $2,528.00 | $6,084.00 | $7,424.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $342.61 / $1,954.75 / $3,623.97
| Professional | | $342.61 | $1,954.75 | $3,623.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $412.88 / $2,027.58 / $2,697.88
| Professional | | $412.88 | $2,027.58 | $2,697.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.55 / $525.92 / $3,778.79
| Professional | | $74.55 | $525.92 | $3,778.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.70 / $2,374.13 / $3,021.62
| Professional | | $261.70 | $2,374.13 | $3,021.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,155.00 / $2,155.00 / $2,155.00
| Facility | | $2,155.00 | $2,155.00 | $2,155.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,201.46 / $2,697.88 / $3,392.12
| Professional | | $2,201.46 | $2,697.88 | $3,392.12 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $335.23 / $8,240.00 / $12,905.00
| Professional | | $335.23 | $8,240.00 | $12,905.00 |