- 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
- $302.00 / $407.38 / $776.25
| Professional | | $302.00 | $407.38 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $478.63 / $588.84
| Professional | | $478.63 | $478.63 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,000.00 / $5,495.41
| Professional | | $758.58 | $1,000.00 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $524.81 / $616.60
| Professional | | $354.81 | $524.81 | $616.60 |
- 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
- $331.13 / $588.84 / $776.25
| Professional | | $331.13 | $588.84 | $776.25 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $426.58 / $676.08
| Professional | | $77.62 | $426.58 | $676.08 |