- 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
- $1,702.29 / $1,702.29 / $1,943.00
| Professional | | $1,702.29 | $1,702.29 | $1,943.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,939.53 / $2,289.67 / $2,289.67
| Professional | | $1,939.53 | $2,289.67 | $2,289.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,434.21 / $2,734.91 / $3,227.19
| Professional | | $2,434.21 | $2,734.91 | $3,227.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,014.91 / $2,198.09 / $2,564.44
| Professional | | $2,014.91 | $2,198.09 | $2,564.44 |
- 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
- $1,868.37 / $2,289.67 / $2,951.84
| Professional | | $1,868.37 | $2,289.67 | $2,951.84 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,845.43 / $2,504.96
| Professional | | $29.27 | $1,845.43 | $2,504.96 |