- 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
- $281.84 / $331.13 / $478.63
| Professional | | $281.84 | $331.13 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $371.54 / $489.78
| Professional | | $346.74 | $371.54 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $478.63 / $2,454.71
| Professional | | $478.63 | $478.63 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $446.68 / $562.34
| Professional | | $371.54 | $446.68 | $562.34 |
- 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
- $257.04 / $380.19 / $501.19
| Professional | | $257.04 | $380.19 | $501.19 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.88 / $363.08 / $478.63
| Professional | | $58.88 | $363.08 | $478.63 |