- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.28 / $11.65 / $14.95
| Facility | | $10.28 | $11.65 | $14.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.82 / $14.95 / $14.95
| Professional | | $9.82 | $14.95 | $14.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.26 / $26.72 / $31.31
| Professional | | $20.26 | $26.72 | $31.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.46 / $14.95 / $18.69
| Professional | | $12.46 | $14.95 | $18.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.23 / $14.95 / $24.20
| Professional | | $5.23 | $14.95 | $24.20 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.70 / $22.43 / $31.34
| Professional | | $14.70 | $22.43 | $31.34 |