- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.20 / $51.48 / $51.48
| Facility | | $0.20 | $51.48 | $51.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.20 / $0.20 / $0.20
| Facility | | $0.20 | $0.20 | $0.20 |
- 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 / $0.05 / $0.06
| Professional | | $0.04 | $0.05 | $0.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.04 / $0.06 / $0.06
| Professional | | $0.04 | $0.06 | $0.06 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.06 / $0.09 / $0.34
| Professional | | $0.06 | $0.09 | $0.34 |