- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,758.00 / $4,456.00 / $5,299.00
| Facility | | $1,758.00 | $4,456.00 | $5,299.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,579.61 / $6,579.61 / $6,579.61
| Professional | | $6,579.61 | $6,579.61 | $6,579.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $696.76 / $696.76 / $696.76
| Professional | | $696.76 | $696.76 | $696.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $670.00 / $670.00 / $670.00
| Professional | | $670.00 | $670.00 | $670.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,981.00 / $1,981.00 / $1,981.00
| Facility | | $1,981.00 | $1,981.00 | $1,981.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,191.00 / $5,191.00 / $5,970.00
| Professional | | $5,191.00 | $5,191.00 | $5,970.00 |