- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.00 / $61.13 / $217.86
| Facility | | $8.00 | $61.13 | $217.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.49 / $2.31 / $8.44
| Professional | | $0.49 | $2.31 | $8.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.01 / $1.01 / $1.01
| Facility | | $1.01 | $1.01 | $1.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.43 / $0.43 / $0.43
| Professional | | $0.43 | $0.43 | $0.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.81 / $2.81 / $2.81
| Professional | | $2.81 | $2.81 | $2.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.47 / $0.52 / $0.60
| Professional | | $0.47 | $0.52 | $0.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.43 / $0.54 / $0.65
| Professional | | $0.43 | $0.54 | $0.65 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.44 / $0.59 / $9.69
| Professional | | $0.44 | $0.59 | $9.69 |