- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,323.00 / $5,323.00 / $5,323.00
| Facility | | $5,323.00 | $5,323.00 | $5,323.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.41 / $4,775.22 / $6,212.45
| Professional | | $615.41 | $4,775.22 | $6,212.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,774.00 / $8,140.31 / $10,179.15
| Professional | | $7,774.00 | $8,140.31 | $10,179.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,132.92 / $6,132.92 / $6,132.92
| Professional | | $6,132.92 | $6,132.92 | $6,132.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,594.91 / $5,323.00 / $6,401.20
| Professional | | $3,594.91 | $5,323.00 | $6,401.20 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,774.00 / $7,774.00 / $7,774.00
| Professional | | $7,774.00 | $7,774.00 | $7,774.00 |