- 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
- $25.12 / $64.57 / $87.10
| Professional | | $25.12 | $64.57 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $72.44 / $89.13
| Professional | | $30.20 | $72.44 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.86 / $66.07 / $2,454.71
| Professional | | $47.86 | $66.07 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.55 / $70.79 / $89.13
| Professional | | $24.55 | $70.79 | $89.13 |
- 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
- $33.11 / $66.07 / $112.20
| Professional | | $33.11 | $66.07 | $112.20 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.39 / $48.98 / $123.03
| Professional | | $22.39 | $48.98 | $123.03 |