- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,482.44 / $5,482.44 / $5,482.44
| Facility | | $5,482.44 | $5,482.44 | $5,482.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.15 / $136.44 / $2,056.54
| Professional | | $131.15 | $136.44 | $2,056.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.16 / $131.16 / $131.16
| Professional | | $131.16 | $131.16 | $131.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.83 / $170.83 / $213.54
| Professional | | $170.83 | $170.83 | $213.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.27 / $157.38 / $183.62
| Professional | | $144.27 | $157.38 | $183.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.41 / $146.01 / $196.74
| Professional | | $140.41 | $146.01 | $196.74 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.55 / $150.94 / $421.13
| Professional | | $96.55 | $150.94 | $421.13 |