- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28.79 / $28.79 / $28.79
| Facility | | $28.79 | $28.79 | $28.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.95 / $18.75 / $36.00
| Professional | | $12.95 | $18.75 | $36.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.37 / $15.37 / $15.37
| Facility | | $15.37 | $15.37 | $15.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.12 / $21.12 / $21.12
| Professional | | $21.12 | $21.12 | $21.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.27 / $2.27 / $2.27
| Professional | | $2.27 | $2.27 | $2.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.00 / $8.00 / $20.00
| Facility | | $8.00 | $8.00 | $20.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.09 / $12.16 / $15.37
| Professional | | $7.09 | $12.16 | $15.37 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.54 / $12.79 / $15.05
| Professional | | $10.54 | $12.79 | $15.05 |