- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6.60 / $7.48 / $9.60
| Facility | | $6.60 | $7.48 | $9.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.71 / $9.60 / $9.60
| Professional | | $4.71 | $9.60 | $9.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.71 / $12.80 / $15.00
| Professional | | $9.71 | $12.80 | $15.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.00 / $9.60 / $12.00
| Professional | | $8.00 | $9.60 | $12.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.33 / $9.60 / $11.57
| Professional | | $8.33 | $9.60 | $11.57 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.75 / $10.97 / $15.41
| Professional | | $8.75 | $10.97 | $15.41 |