- 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 / $354.81 / $524.81
| Professional | | $302.00 | $354.81 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $407.38 / $537.03
| Professional | | $380.19 | $407.38 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $588.84 / $2,630.27
| Professional | | $512.86 | $588.84 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $489.78 / $616.60
| Professional | | $407.38 | $489.78 | $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
- $281.84 / $407.38 / $537.03
| Professional | | $281.84 | $407.38 | $537.03 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.57 / $389.05 / $512.86
| Professional | | $64.57 | $389.05 | $512.86 |