- 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
- $234.42 / $363.08 / $602.56
| Professional | | $234.42 | $363.08 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $457.09 / $630.96
| Professional | | $275.42 | $457.09 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $501.19 / $2,137.96
| Professional | | $398.11 | $501.19 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $489.78 / $630.96
| Professional | | $239.88 | $489.78 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,096.48
| Facility | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $389.05 / $602.56
| Professional | | $199.53 | $389.05 | $602.56 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $1,412.54 / $3,981.07
| Professional | | $323.59 | $1,412.54 | $3,981.07 |