- 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
- $338.84 / $398.11 / $478.63
| Professional | | $338.84 | $398.11 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $436.52 / $478.63
| Professional | | $338.84 | $436.52 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $549.54 / $676.08
| Professional | | $501.19 | $549.54 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $363.08 / $457.09
| Professional | | $323.59 | $363.08 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $436.52 / $575.44
| Professional | | $295.12 | $436.52 | $575.44 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $1,548.82 / $3,981.07
| Professional | | $416.87 | $1,548.82 | $3,981.07 |