- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,505.53 / $1,706.26 / $2,189.86
| Facility | | $1,505.53 | $1,706.26 | $2,189.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.00 / $1,075.00 / $1,075.00
| Professional | | $1,075.00 | $1,075.00 | $1,075.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,363.00 / $2,189.86 / $2,189.86
| Professional | | $1,363.00 | $2,189.86 | $2,189.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,839.54 / $1,926.22 / $2,299.42
| Professional | | $1,839.54 | $1,926.22 | $2,299.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,007.37 / $2,189.86 / $2,554.83
| Professional | | $2,007.37 | $2,189.86 | $2,554.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,189.86 / $2,485.86 / $3,542.35
| Professional | | $2,189.86 | $2,485.86 | $3,542.35 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,551.15 / $2,734.45 / $6,090.36
| Professional | | $1,551.15 | $2,734.45 | $6,090.36 |