- 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
- $316.23 / $346.74 / $512.86
| Professional | | $316.23 | $346.74 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $398.11 / $524.81
| Professional | | $371.54 | $398.11 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $588.84 / $2,570.40
| Professional | | $489.78 | $588.84 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $478.63 / $602.56
| Professional | | $398.11 | $478.63 | $602.56 |
- 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
- $281.84 / $398.11 / $549.54
| Professional | | $281.84 | $398.11 | $549.54 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.10 / $398.11 / $512.86
| Professional | | $63.10 | $398.11 | $512.86 |