- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.08 / $2.08 / $2.08
| Facility | | $2.08 | $2.08 | $2.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.72 / $10.30 / $41.20
| Professional | | $0.72 | $10.30 | $41.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.06 / $2.06 / $2.06
| Facility | | $2.06 | $2.06 | $2.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.70 / $0.70 / $0.70
| Professional | | $0.70 | $0.70 | $0.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.30 / $1.30 / $1.30
| Professional | | $1.30 | $1.30 | $1.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.77 / $0.84 / $0.98
| Professional | | $0.77 | $0.84 | $0.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.70 / $1.05 / $1.07
| Professional | | $0.70 | $1.05 | $1.07 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.66 / $1.10 / $1.91
| Professional | | $0.66 | $1.10 | $1.91 |