- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.68 / $39.92 / $39.92
| Facility | | $1.68 | $39.92 | $39.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.61 / $0.61 / $0.81
| Professional | | $0.61 | $0.61 | $0.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.68 / $1.68 / $1.68
| Facility | | $1.68 | $1.68 | $1.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.59 / $0.59 / $0.59
| Professional | | $0.59 | $0.59 | $0.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.40 / $4.40 / $4.40
| Professional | | $4.40 | $4.40 | $4.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.65 / $0.70 / $0.82
| Professional | | $0.65 | $0.70 | $0.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.59 / $0.68 / $0.89
| Professional | | $0.59 | $0.68 | $0.89 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.56 / $1.00 / $6.12
| Professional | | $0.56 | $1.00 | $6.12 |