- 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
- $204.17 / $380.19 / $416.87
| Professional | | $204.17 | $380.19 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $398.11
| Professional | | $346.74 | $346.74 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $5,888.44 / $8,317.64
| Professional | | $436.52 | $5,888.44 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $389.05 / $446.68
| Professional | | $354.81 | $389.05 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $371.54 / $501.19
| Professional | | $323.59 | $371.54 | $501.19 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $1,548.82 / $3,981.07
| Professional | | $398.11 | $1,548.82 | $3,981.07 |