- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.99 / $11.32 / $14.53
| Facility | | $9.99 | $11.32 | $14.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.48 / $14.48 / $14.48
| Professional | | $14.48 | $14.48 | $14.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.61 / $14.53 / $14.53
| Professional | | $9.61 | $14.53 | $14.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.69 / $25.98 / $30.39
| Professional | | $19.69 | $25.98 | $30.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.11 / $14.53 / $18.17
| Professional | | $12.11 | $14.53 | $18.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.09 / $14.53 / $23.50
| Professional | | $5.09 | $14.53 | $23.50 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.56 / $22.00 / $30.46
| Professional | | $13.56 | $22.00 | $30.46 |