- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,900.00 / $11,220.00 / $14,400.00
| Facility | | $9,900.00 | $11,220.00 | $14,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Professional | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,400.00 / $14,400.00 / $14,400.00
| Professional | | $14,400.00 | $14,400.00 | $14,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,680.62 / $12,565.44 / $15,000.00
| Professional | | $10,680.62 | $12,565.44 | $15,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,000.00 / $14,400.00 / $18,000.00
| Professional | | $12,000.00 | $14,400.00 | $18,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,000.00 / $14,400.00 / $18,000.00
| Professional | | $12,000.00 | $14,400.00 | $18,000.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,200.00 / $17,640.00 / $27,000.00
| Professional | | $10,200.00 | $17,640.00 | $27,000.00 |