- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.98 / $57.95 / $57.95
| Professional | | $29.98 | $57.95 | $57.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.86 / $38.04 / $69.54
| Professional | | $28.86 | $38.04 | $69.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $50.96 / $56.62
| Professional | | $30.00 | $50.96 | $56.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.51 / $40.92 / $55.63
| Professional | | $37.51 | $40.92 | $55.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.50 / $40.18 / $57.95
| Professional | | $39.50 | $40.18 | $57.95 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.50 / $39.22 / $51.30
| Professional | | $31.50 | $39.22 | $51.30 |