- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $786.64 / $786.65 / $1,487.77
| Professional | | $786.64 | $786.65 | $1,487.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $876.17 / $1,111.93 / $1,500.95
| Professional | | $876.17 | $1,111.93 | $1,500.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.16 / $208.81 / $7,637.00
| Professional | | $183.16 | $208.81 | $7,637.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $978.49 / $1,067.45 / $1,245.35
| Professional | | $978.49 | $1,067.45 | $1,245.35 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $134.28 / $146.47 / $170.90
| Professional | 26 | $134.28 | $146.47 | $170.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $907.33 / $1,111.93 / $1,451.44
| Professional | | $907.33 | $1,111.93 | $1,451.44 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.65 / $1,300.76 / $16,115.00
| Professional | | $891.65 | $1,300.76 | $16,115.00 |