- 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
- $416.87 / $457.09 / $630.96
| Professional | | $416.87 | $457.09 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $524.81 / $645.65
| Professional | | $457.09 | $524.81 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $660.69 / $794.33
| Professional | | $602.56 | $660.69 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $524.81 / $645.65
| Professional | | $457.09 | $524.81 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $512.86 / $724.44
| Professional | | $354.81 | $512.86 | $724.44 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $1,548.82 / $3,981.07
| Professional | | $537.03 | $1,548.82 | $3,981.07 |