- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,630.05 / $1,630.05 / $1,630.05
| Professional | | $1,630.05 | $1,630.05 | $1,630.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,200.00 / $7,200.00 / $7,200.00
| Facility | | $7,200.00 | $7,200.00 | $7,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,214.74 / $3,214.74 / $4,717.63
| Professional | | $3,214.74 | $3,214.74 | $4,717.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,000.00 / $10,000.00 / $10,000.00
| Professional | | $10,000.00 | $10,000.00 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,865.62 / $4,288.75 / $6,004.25
| Professional | | $2,865.62 | $4,288.75 | $6,004.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,761.65 / $4,245.85 / $7,200.00
| Professional | | $2,761.65 | $4,245.85 | $7,200.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,454.75 / $3,573.15 / $4,082.10
| Professional | | $3,454.75 | $3,573.15 | $4,082.10 |