- 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
- $974.76 / $974.76 / $974.76
| Professional | | $974.76 | $974.76 | $974.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,665.04 / $1,816.40 / $2,119.14
| Professional | | $1,665.04 | $1,816.40 | $2,119.14 |
- 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
- $1,897.79 / $2,190.63 / $2,587.83
| Professional | | $1,897.79 | $2,190.63 | $2,587.83 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $29.27 / $29.27
| Professional | | $29.27 | $29.27 | $29.27 |