- 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
- $309.03 / $354.81 / $794.33
| Professional | | $309.03 | $354.81 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $398.11 / $478.63
| Professional | | $338.84 | $398.11 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $562.34 / $2,818.38
| Professional | | $501.19 | $562.34 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $398.11 / $501.19
| Professional | | $354.81 | $398.11 | $501.19 |
- 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
- $269.15 / $436.52 / $549.54
| Professional | | $269.15 | $436.52 | $549.54 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $2,454.71 / $3,981.07
| Professional | | $457.09 | $2,454.71 | $3,981.07 |