- 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
- $426.58 / $446.68 / $537.03
| Professional | | $426.58 | $446.68 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $489.78 / $512.86
| Professional | | $407.38 | $489.78 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $758.58 / $7,943.28
| Professional | | $588.84 | $758.58 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $467.74 / $575.44
| Professional | | $426.58 | $467.74 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Facility | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $512.86 / $660.69
| Professional | | $426.58 | $512.86 | $660.69 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $1,548.82 / $3,981.07
| Professional | | $489.78 | $1,548.82 | $3,981.07 |