- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.27 / $2.27 / $2.27
| Facility | | $2.27 | $2.27 | $2.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.11 / $1.12 / $1,998.00
| Professional | | $1.11 | $1.12 | $1,998.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.27 / $2.27 / $2.27
| Facility | | $2.27 | $2.27 | $2.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.11 / $1.11 / $1.11
| Professional | | $1.11 | $1.11 | $1.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.62 / $1.62 / $1.62
| Professional | | $1.62 | $1.62 | $1.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.22 / $1.33 / $1.55
| Professional | | $1.22 | $1.33 | $1.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.11 / $1.33 / $1.67
| Professional | | $1.11 | $1.33 | $1.67 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.12 / $1.31 / $1.42
| Professional | | $1.12 | $1.31 | $1.42 |