- 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
- $64.57 / $85.11 / $134.90
| Professional | | $64.57 | $85.11 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $120.23
| Professional | | $100.00 | $100.00 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $138.04 / $169.82
| Professional | | $125.89 | $138.04 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $114.82 / $144.54
| Professional | | $87.10 | $114.82 | $144.54 |
- 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
- $79.43 / $117.49 / $158.49
| Professional | | $79.43 | $117.49 | $158.49 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $1,548.82 / $3,981.07
| Professional | | $93.33 | $1,548.82 | $3,981.07 |