- 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
- $288.40 / $416.87 / $602.56
| Professional | | $288.40 | $416.87 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $489.78 / $1,348.96
| Professional | | $316.23 | $489.78 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $588.84 / $691.83
| Professional | | $512.86 | $588.84 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $549.54 / $707.95
| Professional | | $338.84 | $549.54 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $446.68 / $660.69
| Professional | | $288.40 | $446.68 | $660.69 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $389.05 / $676.08
| Professional | | $85.11 | $389.05 | $676.08 |