- 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
- $315.64 / $398.45 / $422.54
| Professional | | $315.64 | $398.45 | $422.54 |
- 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
- $254.11 / $439.55 / $466.89
| Professional | | $254.11 | $439.55 | $466.89 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,435.00 / $12,600.00 / $22,500.00
| Professional | | $9,435.00 | $12,600.00 | $22,500.00 |