- 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
- $109.65 / $281.84 / $794.33
| Professional | | $109.65 | $281.84 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $275.42 / $1,348.96
| Professional | | $141.25 | $275.42 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $239.88 / $6,456.54
| Professional | | $173.78 | $239.88 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $562.34 / $707.95
| Professional | | $100.00 | $562.34 | $707.95 |
- 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
- $134.90 / $436.52 / $891.25
| Professional | | $134.90 | $436.52 | $891.25 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $147.91 / $831.76
| Professional | | $93.33 | $147.91 | $831.76 |