- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.10 / $6.10 / $6.10
| Professional | | $6.10 | $6.10 | $6.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.88 / $20.88 / $20.88
| Facility | | $20.88 | $20.88 | $20.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.58 / $8.58 / $28.93
| Professional | | $8.58 | $8.58 | $28.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.30 / $27.54 / $27.54
| Professional | | $26.30 | $27.54 | $27.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.78 / $26.30 / $36.82
| Professional | | $15.78 | $26.30 | $36.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.15 / $20.88 / $28.93
| Professional | | $7.15 | $20.88 | $28.93 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.96 / $21.91 / $25.03
| Professional | | $17.96 | $21.91 | $25.03 |