- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,747.00 / $2,747.00 / $2,747.00
| Facility | | $2,747.00 | $2,747.00 | $2,747.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,481.00 / $1,481.00 / $1,483.45
| Professional | | $1,481.00 | $1,481.00 | $1,483.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,418.11 / $1,891.03 / $1,891.03
| Professional | | $1,418.11 | $1,891.03 | $1,891.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,030.49 / $2,281.31 / $2,691.95
| Professional | | $2,030.49 | $2,281.31 | $2,691.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,664.10 / $1,815.38 / $2,117.94
| Professional | | $1,664.10 | $1,815.38 | $2,117.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.00 / $2,446.00 / $2,446.00
| Facility | | $2,446.00 | $2,446.00 | $2,446.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,543.08 / $1,891.03 / $2,474.92
| Professional | | $1,543.08 | $1,891.03 | $2,474.92 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,482.01 / $2,293.44
| Professional | | $29.27 | $1,482.01 | $2,293.44 |