- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.80 / $16.60 / $19.95
| Facility | | $13.80 | $16.60 | $19.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.02 / $15.14 / $15.85
| Professional | | $12.02 | $15.14 | $15.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.49 / $13.49 / $19.95
| Professional | | $13.49 | $13.49 | $19.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.84 / $37.15 / $40.74
| Professional | | $28.84 | $37.15 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.60 / $19.95 / $25.12
| Professional | | $16.60 | $19.95 | $25.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.08 / $23.44 / $32.36
| Professional | | $7.08 | $23.44 | $32.36 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.62 / $30.20 / $41.69
| Professional | | $18.62 | $30.20 | $41.69 |