- 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
- $275.42 / $323.59 / $489.78
| Professional | | $275.42 | $323.59 | $489.78 |
- 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
- $467.74 / $537.03 / $2,630.27
| Professional | | $467.74 | $537.03 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $446.68 / $575.44
| Professional | | $363.08 | $446.68 | $575.44 |
- 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 / $371.54 / $478.63
| Professional | | $257.04 | $371.54 | $478.63 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.88 / $346.74 / $478.63
| Professional | | $58.88 | $346.74 | $478.63 |