- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Facility | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.03 / $10.00 / $19.95
| Professional | | $6.03 | $10.00 | $19.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.14 / $15.14 / $18.62
| Professional | | $15.14 | $15.14 | $18.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.30 / $16.98 / $2,454.71
| Professional | | $12.30 | $16.98 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.76 / $16.98 / $19.95
| Professional | | $7.76 | $16.98 | $19.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.33 / $15.14 / $23.44
| Professional | | $9.33 | $15.14 | $23.44 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.61 / $13.18 / $26.92
| Professional | | $6.61 | $13.18 | $26.92 |