- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.01 / $313.93 / $519.46
| Professional | | $214.01 | $313.93 | $519.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.45 / $420.61 / $515.45
| Professional | | $319.45 | $420.61 | $515.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.57 / $340.12 / $627.41
| Professional | | $149.57 | $340.12 | $627.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $453.60 / $494.83 / $577.29
| Professional | | $453.60 | $494.83 | $577.29 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $118.59 / $129.37 / $150.93
| Professional | 26 | $118.59 | $129.37 | $150.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.60 / $497.59 / $660.18
| Professional | | $396.60 | $497.59 | $660.18 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.32 / $392.61 / $572.74
| Professional | | $285.32 | $392.61 | $572.74 |