- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.97 / $19.97 / $19.97
| Facility | | $19.97 | $19.97 | $19.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.40 / $14.40 / $18.16
| Professional | | $14.40 | $14.40 | $18.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.97 / $19.97 / $19.97
| Facility | | $19.97 | $19.97 | $19.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.00 / $90.35 / $115.68
| Professional | | $37.00 | $90.35 | $115.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.52 / $16.92 / $19.37
| Professional | | $14.52 | $16.92 | $19.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.57 / $7.73 / $7.73
| Professional | | $6.57 | $7.73 | $7.73 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.58 / $18.52 / $257.50
| Professional | | $11.58 | $18.52 | $257.50 |