- 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
- $39.81 / $89.13 / $223.87
| Professional | | $39.81 | $89.13 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $123.03 / $151.36
| Professional | | $123.03 | $123.03 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $117.49 / $2,454.71
| Professional | | $87.10 | $117.49 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $131.83 / $158.49
| Professional | | $57.54 | $131.83 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.07 / $112.20 / $186.21
| Professional | | $66.07 | $112.20 | $186.21 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.66 / $2,041.74 / $3,981.07
| Professional | | $61.66 | $2,041.74 | $3,981.07 |