- 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
- $436.52 / $489.78 / $691.83
| Professional | | $436.52 | $489.78 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $562.34 / $691.83
| Professional | | $489.78 | $562.34 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $776.25 / $2,630.27
| Professional | | $676.08 | $776.25 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $616.60 / $794.33
| Professional | | $537.03 | $616.60 | $794.33 |
- 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
- $380.19 / $549.54 / $776.25
| Professional | | $380.19 | $549.54 | $776.25 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $549.54 / $676.08
| Professional | | $85.11 | $549.54 | $676.08 |