- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,995.26 / $2,398.83
| Facility | | $1,659.59 | $1,995.26 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,737.80 / $2,511.89
| Professional | | $1,000.00 | $1,737.80 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Professional | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,238.72 / $2,511.89
| Professional | | $1,995.26 | $2,238.72 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,398.83 / $3,019.95
| Professional | | $2,187.76 | $2,398.83 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,995.26 / $3,019.95
| Professional | | $1,000.00 | $1,995.26 | $3,019.95 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,691.53 / $3,630.78
| Professional | | $1,698.24 | $2,691.53 | $3,630.78 |