- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $7.94 / $9.12 / $10.72
| Facility | 26 | $7.94 | $9.12 | $10.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.92 / $33.88 / $109.65
| Professional | | $26.92 | $33.88 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.84 / $46.77 / $77.62
| Professional | | $28.84 | $46.77 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.48 / $51.29 / $57.54
| Professional | | $35.48 | $51.29 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.66 / $45.71 / $53.70
| Professional | | $42.66 | $45.71 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $8.91 / $9.77 / $11.48
| Professional | 26 | $8.91 | $9.77 | $11.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.90 / $50.12 / $69.18
| Professional | | $38.90 | $50.12 | $69.18 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $54.95 / $97.72
| Professional | | $44.67 | $54.95 | $97.72 |