- 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
- $154.88 / $251.19 / $426.58
| Professional | | $154.88 | $251.19 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $338.84 / $457.09
| Professional | | $194.98 | $338.84 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $331.13 / $2,137.96
| Professional | | $269.15 | $331.13 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $380.19 / $478.63
| Professional | | $190.55 | $380.19 | $478.63 |
- 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
- $141.25 / $275.42 / $416.87
| Professional | | $141.25 | $275.42 | $416.87 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $1,412.54 / $3,981.07
| Professional | | $229.09 | $1,412.54 | $3,981.07 |