- 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
- $97.72 / $234.42 / $660.69
| Professional | | $97.72 | $234.42 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $295.12 / $741.31
| Professional | | $112.20 | $295.12 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $239.88 / $2,454.71
| Professional | | $177.83 | $239.88 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $338.84 / $426.58
| Professional | | $102.33 | $338.84 | $426.58 |
- 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
- $151.36 / $331.13 / $954.99
| Professional | | $151.36 | $331.13 | $954.99 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $2,454.71 / $3,981.07
| Professional | | $316.23 | $2,454.71 | $3,981.07 |