- 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
- $1,759.31 / $1,759.31 / $2,000.50
| Professional | | $1,759.31 | $1,759.31 | $2,000.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,996.56 / $2,367.46 / $2,367.46
| Professional | | $1,996.56 | $2,367.46 | $2,367.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,517.96 / $2,829.00 / $3,338.22
| Professional | | $2,517.96 | $2,829.00 | $3,338.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,083.37 / $2,272.76 / $2,651.56
| Professional | | $2,083.37 | $2,272.76 | $2,651.56 |
- 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
- $1,931.85 / $2,367.46 / $3,048.00
| Professional | | $1,931.85 | $2,367.46 | $3,048.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,898.13 / $2,591.14
| Professional | | $29.27 | $1,898.13 | $2,591.14 |