- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,884.03 / $2,884.03
| Facility | | $1,000.00 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $151.36 / $346.74
| Professional | | $100.00 | $151.36 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $181.97 / $223.87
| Professional | | $181.97 | $181.97 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $245.47 / $4,570.88
| Professional | | $199.53 | $245.47 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $204.17 / $234.42
| Professional | | $141.25 | $204.17 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Facility | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $181.97 / $281.84
| Professional | | $125.89 | $181.97 | $281.84 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $3,548.13 / $5,495.41
| Professional | | $131.83 | $3,548.13 | $5,495.41 |