- 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
- $151.36 / $524.81 / $1,258.93
| Professional | | $151.36 | $524.81 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $1,023.29 / $1,071.52
| Professional | | $194.98 | $1,023.29 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $331.13 / $9,549.93
| Professional | | $263.03 | $331.13 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $870.96 / $1,071.52
| Professional | | $144.54 | $870.96 | $1,071.52 |
- 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
- $194.98 / $851.14 / $1,318.26
| Professional | | $194.98 | $851.14 | $1,318.26 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $199.53 / $2,137.96
| Professional | | $134.90 | $199.53 | $2,137.96 |