- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,747.00 / $8,431.00 / $10,303.00
| Facility | | $2,747.00 | $8,431.00 | $10,303.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.84 / $441.62 / $468.31
| Professional | | $349.84 | $441.62 | $468.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,912.00 / $2,912.00 / $2,912.00
| Facility | | $2,912.00 | $2,912.00 | $2,912.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.93 / $487.18 / $517.14
| Professional | | $281.93 | $487.18 | $517.14 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,600.00 / $12,600.00 / $13,230.00
| Professional | | $12,600.00 | $12,600.00 | $13,230.00 |