- 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
- $22.91 / $25.12 / $32.36
| Professional | | $22.91 | $25.12 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.92 / $30.20 / $43.65
| Professional | | $26.92 | $30.20 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.48 / $39.81 / $44.67
| Professional | | $35.48 | $39.81 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.70 / $29.51 / $38.02
| Professional | | $25.70 | $29.51 | $38.02 |
- 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
- $24.55 / $31.62 / $40.74
| Professional | | $24.55 | $31.62 | $40.74 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.39 / $22.39 / $22.39
| Professional | | $22.39 | $22.39 | $22.39 |