- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.41 / $2.41 / $2.41
| Professional | | $2.41 | $2.41 | $2.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.72 / $4.72 / $4.72
| Facility | | $4.72 | $4.72 | $4.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.86 / $3.41 / $6.52
| Professional | | $2.86 | $3.41 | $6.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.93 / $6.21 / $6.21
| Professional | | $5.93 | $6.21 | $6.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.15 / $5.93 / $8.30
| Professional | | $4.15 | $5.93 | $8.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.92 / $5.87 / $6.52
| Professional | | $2.92 | $5.87 | $6.52 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.04 / $4.94 / $5.64
| Professional | | $4.04 | $4.94 | $5.64 |