- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,528.00 / $6,084.00 / $7,424.00
| Facility | | $2,528.00 | $6,084.00 | $7,424.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,800.00 / $3,800.00 / $3,800.00
| Professional | | $3,800.00 | $3,800.00 | $3,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,141.25 / $5,141.25 / $5,141.25
| Professional | | $5,141.25 | $5,141.25 | $5,141.25 |
- 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 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,761.00 / $4,492.07 / $5,675.00
| Professional | | $1,761.00 | $4,492.07 | $5,675.00 |