- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,855.86 / $4,000.45 / $4,096.85
| Professional | | $3,855.86 | $4,000.45 | $4,096.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,819.82 / $4,819.82 / $6,352.22
| Professional | | $4,819.82 | $4,819.82 | $6,352.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,759.68 / $5,759.68 / $5,759.68
| Professional | | $5,759.68 | $5,759.68 | $5,759.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.00 / $5.00 / $670.00
| Professional | | $5.00 | $5.00 | $670.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,399.80 / $5,684.00 / $8,526.00
| Professional | | $5,399.80 | $5,684.00 | $8,526.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,200.00 / $5,100.00 / $6,000.00
| Professional | | $4,200.00 | $5,100.00 | $6,000.00 |