- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.49 / $16.22 / $19.95
| Facility | | $13.49 | $16.22 | $19.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.02 / $15.14 / $15.14
| Professional | | $12.02 | $15.14 | $15.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.88 / $12.88 / $19.95
| Professional | | $12.88 | $12.88 | $19.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.18 / $40.74 / $40.74
| Professional | | $28.18 | $40.74 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.60 / $19.95 / $24.55
| Professional | | $16.60 | $19.95 | $24.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.92 / $22.91 / $31.62
| Professional | | $6.92 | $22.91 | $31.62 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.62 / $29.51 / $41.69
| Professional | | $18.62 | $29.51 | $41.69 |