- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.95 / $23.99 / $28.84
| Facility | | $19.95 | $23.99 | $28.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.20 / $21.88 / $22.91
| Professional | | $18.20 | $21.88 | $22.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.05 / $19.05 / $28.84
| Professional | | $19.05 | $19.05 | $28.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.69 / $53.70 / $60.26
| Professional | | $41.69 | $53.70 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.55 / $28.84 / $36.31
| Professional | | $24.55 | $28.84 | $36.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.23 / $33.88 / $46.77
| Professional | | $10.23 | $33.88 | $46.77 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.92 / $43.65 / $61.66
| Professional | | $26.92 | $43.65 | $61.66 |