- 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
- $234.42 / $354.81 / $831.76
| Professional | | $234.42 | $354.81 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $446.68 / $446.68 / $446.68
| Professional | 50 | $446.68 | $446.68 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $331.13 / $389.05
| Professional | | $331.13 | $331.13 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $645.65 / $2,691.53
| Professional | | $501.19 | $645.65 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $354.81 / $416.87
| Professional | | $234.42 | $354.81 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,096.48
| Facility | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $389.05 / $501.19
| Professional | | $295.12 | $389.05 | $501.19 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $1,621.81 / $3,981.07
| Professional | | $275.42 | $1,621.81 | $3,981.07 |