- 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
- $269.15 / $309.03 / $478.63
| Professional | | $269.15 | $309.03 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $338.84 / $446.68
| Professional | | $316.23 | $338.84 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $501.19 / $2,454.71
| Professional | | $446.68 | $501.19 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $407.38 / $512.86
| Professional | | $338.84 | $407.38 | $512.86 |
- 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
- $239.88 / $346.74 / $467.74
| Professional | | $239.88 | $346.74 | $467.74 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.95 / $363.08 / $436.52
| Professional | | $54.95 | $363.08 | $436.52 |