- 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
- $3,501.64 / $3,501.64 / $3,501.64
| Professional | | $3,501.64 | $3,501.64 | $3,501.64 |
- 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
- $2,352.01 / $4,046.46 / $6,133.59
| Professional | | $2,352.01 | $4,046.46 | $6,133.59 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $29.27 / $29.27
| Professional | | $29.27 | $29.27 | $29.27 |