- 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
- $660.69 / $741.31 / $1,023.29
| Professional | | $660.69 | $741.31 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $831.76 / $1,000.00
| Professional | | $707.95 | $831.76 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,047.13 / $1,258.93
| Professional | | $954.99 | $1,047.13 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $831.76 / $1,023.29
| Professional | | $724.44 | $831.76 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $851.14 / $1,148.15
| Professional | | $575.44 | $851.14 | $1,148.15 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,548.82 / $3,981.07
| Professional | | $758.58 | $1,548.82 | $3,981.07 |