- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.12 / $507.45 / $507.45
| Facility | | $0.12 | $507.45 | $507.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.13 / $0.13 / $0.13
| Facility | | $0.13 | $0.13 | $0.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.04 / $0.04 / $0.04
| Professional | | $0.04 | $0.04 | $0.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.07 / $0.07 / $0.07
| Professional | | $0.07 | $0.07 | $0.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.04 / $0.04 / $0.05
| Professional | | $0.04 | $0.04 | $0.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.04 / $0.05 / $0.06
| Professional | | $0.04 | $0.05 | $0.06 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.03 / $0.06 / $0.14
| Professional | | $0.03 | $0.06 | $0.14 |