- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.71 / $184.71 / $184.71
| Professional | | $184.71 | $184.71 | $184.71 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $32.79 / $32.79 / $32.79
| Professional | 26 | $32.79 | $32.79 | $32.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.75 / $181.86 / $309.05
| Professional | | $33.75 | $181.86 | $309.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $37.93 / $39.71 / $56.24
| Professional | 26 | $37.93 | $39.71 | $56.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.55 / $177.32 / $206.88
| Professional | | $162.55 | $177.32 | $206.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $28.86 / $31.49 / $36.74
| Professional | 26 | $28.86 | $31.49 | $36.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.71 / $184.71 / $190.58
| Professional | | $184.71 | $184.71 | $190.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $32.79 / $32.79 / $44.07
| Professional | 26 | $32.79 | $32.79 | $44.07 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.39 / $202.55 / $293.04
| Professional | | $103.39 | $202.55 | $293.04 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $25.44 / $38.44 / $51.14
| Professional | 26 | $25.44 | $38.44 | $51.14 |