- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $190.55 / $288.40
| Professional | | $158.49 | $190.55 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $229.09 / $295.12
| Professional | | $165.96 | $229.09 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $213.80 / $281.84
| Professional | | $79.43 | $213.80 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $263.03 / $331.13
| Professional | | $239.88 | $263.03 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $60.26 / $66.07 / $83.18
| Professional | 26 | $60.26 | $66.07 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $223.87 / $251.19
| Professional | | $177.83 | $223.87 | $251.19 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $199.53 / $288.40
| Professional | | $147.91 | $199.53 | $288.40 |