- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,528.00 / $2,747.00 / $6,084.00
| Facility | | $2,528.00 | $2,747.00 | $6,084.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $916.53 / $916.53 / $916.53
| Professional | | $916.53 | $916.53 | $916.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,028.00 / $3,028.00 / $3,028.00
| Facility | | $3,028.00 | $3,028.00 | $3,028.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $922.76 / $1,742.09 / $1,963.35
| Professional | | $922.76 | $1,742.09 | $1,963.35 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,108.88 / $12,599.00 / $22,500.00
| Professional | | $8,108.88 | $12,599.00 | $22,500.00 |