- 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
- $51.29 / $53.70 / $67.61
| Professional | | $51.29 | $53.70 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.88 / $64.57 / $93.33
| Professional | | $58.88 | $64.57 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.18 / $77.62 / $85.11
| Professional | | $69.18 | $77.62 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $58.88 / $74.13
| Professional | | $50.12 | $58.88 | $74.13 |
- 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
- $52.48 / $69.18 / $87.10
| Professional | | $52.48 | $69.18 | $87.10 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.71 / $45.71 / $45.71
| Professional | | $45.71 | $45.71 | $45.71 |