- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.00 / $12.02 / $100.00
| Facility | | $10.00 | $12.02 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.12 / $10.96 / $14.45
| Professional | | $9.12 | $10.96 | $14.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.55 / $9.55 / $14.45
| Professional | | $9.55 | $9.55 | $14.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.89 / $26.92 / $29.51
| Professional | | $20.89 | $26.92 | $29.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.02 / $14.45 / $23.44
| Professional | | $12.02 | $14.45 | $23.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.13 / $16.98 / $23.44
| Professional | | $5.13 | $16.98 | $23.44 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.02 / $21.88 / $30.20
| Professional | | $12.02 | $21.88 | $30.20 |