- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $21.38 / $21.38
| Professional | | $21.38 | $21.38 | $21.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $49.90 / $49.90 / $49.90
| Facility | | $49.90 | $49.90 | $49.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.36 / $38.36 / $69.09
| Professional | | $38.36 | $38.36 | $69.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.81 / $65.77 / $65.77
| Professional | | $62.81 | $65.77 | $65.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.69 / $62.81 / $87.93
| Professional | | $37.69 | $62.81 | $87.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.77 / $49.90 / $69.09
| Professional | | $43.77 | $49.90 | $69.09 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.60 / $52.33 / $59.79
| Professional | | $50.60 | $52.33 | $59.79 |