- 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 / $478.63 / $691.83
| Professional | | $416.87 | $478.63 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $537.03 / $707.95
| Professional | | $501.19 | $537.03 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $707.95 / $2,454.71
| Professional | | $691.83 | $707.95 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $630.96 / $794.33
| Professional | | $512.86 | $630.96 | $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
- $371.54 / $549.54 / $724.44
| Professional | | $371.54 | $549.54 | $724.44 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $524.81 / $691.83
| Professional | | $85.11 | $524.81 | $691.83 |