- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.60 / $19.95 / $23.99
| Facility | | $16.60 | $19.95 | $23.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.13 / $18.20 / $30.90
| Professional | | $14.13 | $18.20 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.13 / $15.85 / $23.99
| Professional | | $14.13 | $15.85 | $23.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $44.67 / $48.98
| Professional | | $34.67 | $44.67 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.88 / $23.99 / $30.20
| Professional | | $21.88 | $23.99 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.13 / $23.99 / $38.90
| Professional | | $14.13 | $23.99 | $38.90 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.39 / $36.31 / $50.12
| Professional | | $22.39 | $36.31 | $50.12 |