- 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
- $173.78 / $269.15 / $478.63
| Professional | | $173.78 | $269.15 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $281.84 / $446.68
| Professional | | $186.21 | $281.84 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $380.19 / $2,454.71
| Professional | | $309.03 | $380.19 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $407.38 / $512.86
| Professional | | $245.47 | $407.38 | $512.86 |
- 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
- $213.80 / $331.13 / $501.19
| Professional | | $213.80 | $331.13 | $501.19 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $1,548.82 / $3,981.07
| Professional | | $338.84 | $1,548.82 | $3,981.07 |