- 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
- $51.29 / $51.29 / $51.29
| Professional | | $51.29 | $51.29 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $181.97 / $2,511.89
| Professional | | $134.90 | $181.97 | $2,511.89 |
- 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
- $213.80 / $213.80 / $251.19
| Professional | | $213.80 | $213.80 | $251.19 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.65 / $4.68 / $29.51
| Professional | | $0.65 | $4.68 | $29.51 |