- 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
- $446.68 / $512.86 / $758.58
| Professional | | $446.68 | $512.86 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $562.34 / $741.31
| Professional | | $524.81 | $562.34 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $2,454.71
| Professional | | $741.31 | $741.31 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $660.69 / $851.14
| Professional | | $524.81 | $660.69 | $851.14 |
- 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
- $407.38 / $588.84 / $776.25
| Professional | | $407.38 | $588.84 | $776.25 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $575.44 / $724.44
| Professional | | $91.20 | $575.44 | $724.44 |