- 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
- $1,681.18 / $1,725.23 / $1,725.23
| Professional | | $1,681.18 | $1,725.23 | $1,725.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,620.54 / $2,001.19 / $2,001.19
| Professional | | $1,620.54 | $2,001.19 | $2,001.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,251.37 / $2,529.48 / $2,984.79
| Professional | | $2,251.37 | $2,529.48 | $2,984.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,761.05 / $1,921.14 / $2,241.33
| Professional | | $1,761.05 | $1,921.14 | $2,241.33 |
- 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
- $1,632.97 / $2,001.46 / $2,611.96
| Professional | | $1,632.97 | $2,001.46 | $2,611.96 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,438.80 / $2,166.66
| Professional | | $29.27 | $1,438.80 | $2,166.66 |