- 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 / $316.23 / $741.31
| Professional | | $97.72 | $316.23 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $229.09 / $977.24
| Professional | | $114.82 | $229.09 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $208.93 / $2,344.23
| Professional | | $151.36 | $208.93 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $549.54 / $691.83
| Professional | | $83.18 | $549.54 | $691.83 |
- 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
- $109.65 / $380.19 / $724.44
| Professional | | $109.65 | $380.19 | $724.44 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $123.03 / $794.33
| Professional | | $75.86 | $123.03 | $794.33 |