- 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
- $89.13 / $120.23 / $186.21
| Professional | | $89.13 | $120.23 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $131.83 / $154.88
| Professional | | $131.83 | $131.83 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $194.98 / $2,691.53
| Professional | | $158.49 | $194.98 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $141.25 / $165.96
| Professional | | $79.43 | $141.25 | $165.96 |
- 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 / $144.54 / $194.98
| Professional | | $109.65 | $144.54 | $194.98 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $1,412.54 / $3,981.07
| Professional | | $117.49 | $1,412.54 | $3,981.07 |