- 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
- $316.23 / $389.05 / $501.19
| Professional | | $316.23 | $389.05 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $426.58 / $512.86
| Professional | | $363.08 | $426.58 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $562.34 / $5,011.87
| Professional | | $478.63 | $562.34 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $457.09 / $575.44
| Professional | | $407.38 | $457.09 | $575.44 |
- 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
- $281.84 / $389.05 / $575.44
| Professional | | $281.84 | $389.05 | $575.44 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $1,548.82 / $3,981.07
| Professional | | $426.58 | $1,548.82 | $3,981.07 |