- 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
- $7.08 / $7.08 / $10.00
| Professional | | $7.08 | $7.08 | $10.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.46 / $9.77 / $17.38
| Professional | | $6.46 | $9.77 | $17.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.32 / $11.22 / $18.62
| Professional | | $8.32 | $11.22 | $18.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.32 / $11.75 / $22.39
| Professional | | $8.32 | $11.75 | $22.39 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.60 / $27.54 / $30.20
| Professional | | $16.60 | $27.54 | $30.20 |