- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.95 / $24.95 / $24.95
| Professional | | $24.95 | $24.95 | $24.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58.21 / $58.21 / $58.21
| Facility | | $58.21 | $58.21 | $58.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.91 / $41.91 / $80.59
| Professional | | $41.91 | $41.91 | $80.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.27 / $76.72 / $76.72
| Professional | | $73.27 | $76.72 | $76.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.96 / $73.27 / $102.58
| Professional | | $43.96 | $73.27 | $102.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.47 / $58.21 / $80.59
| Professional | | $44.47 | $58.21 | $80.59 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.03 / $61.05 / $69.73
| Professional | | $59.03 | $61.05 | $69.73 |