- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,970.00 / $3,366.00 / $4,320.00
| Facility | | $2,970.00 | $3,366.00 | $4,320.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,908.00 / $1,908.00 / $1,908.00
| Professional | | $1,908.00 | $1,908.00 | $1,908.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,025.36 / $4,320.00 / $4,320.00
| Professional | | $2,025.36 | $4,320.00 | $4,320.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,934.56 / $4,371.72 / $5,218.75
| Professional | | $3,934.56 | $4,371.72 | $5,218.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,960.00 / $4,320.00 / $5,040.00
| Professional | | $3,960.00 | $4,320.00 | $5,040.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,600.00 / $4,320.00 / $5,400.00
| Professional | | $3,600.00 | $4,320.00 | $5,400.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,060.00 / $4,860.00 / $8,100.00
| Professional | | $3,060.00 | $4,860.00 | $8,100.00 |