- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.97 / $12.97 / $12.97
| Facility | | $12.97 | $12.97 | $12.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.84 / $12.55 / $27.06
| Professional | | $10.84 | $12.55 | $27.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.42 / $9.42 / $9.42
| Professional | | $9.42 | $9.42 | $9.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.43 / $23.39 / $28.46
| Professional | | $18.43 | $23.39 | $28.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.10 / $15.72 / $18.34
| Professional | | $13.10 | $15.72 | $18.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.50 / $15.72 / $23.27
| Professional | | $5.50 | $15.72 | $23.27 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.44 / $21.62 / $22.46
| Professional | | $18.44 | $21.62 | $22.46 |