- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,554.68 / $3,554.68 / $3,554.68
| Facility | | $3,554.68 | $3,554.68 | $3,554.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,554.67 / $3,554.67 / $3,554.67
| Facility | | $3,554.67 | $3,554.67 | $3,554.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.00 / $816.00 / $816.00
| Professional | | $816.00 | $816.00 | $816.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,667.92 / $1,667.92 / $1,667.92
| Professional | | $1,667.92 | $1,667.92 | $1,667.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $800.00 / $1,200.00 / $1,370.89
| Professional | | $800.00 | $1,200.00 | $1,370.89 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.50 / $1,382.32 / $3,187.78
| Professional | | $48.50 | $1,382.32 | $3,187.78 |