- 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
- $151.36 / $229.09 / $354.81
| Professional | | $151.36 | $229.09 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $275.42 / $371.54
| Professional | | $194.98 | $275.42 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $338.84 / $2,137.96
| Professional | | $263.03 | $338.84 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $288.40 / $371.54
| Professional | | $162.18 | $288.40 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,096.48
| Facility | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $257.04 / $371.54
| Professional | | $128.82 | $257.04 | $371.54 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $1,202.26 / $3,981.07
| Professional | | $190.55 | $1,202.26 | $3,981.07 |