- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7.68 / $93.83 / $93.83
| Facility | | $7.68 | $93.83 | $93.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.29 / $2.31 / $42.09
| Professional | | $2.29 | $2.31 | $42.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.83 / $3.83 / $3.83
| Facility | | $3.83 | $3.83 | $3.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.95 / $2.29 / $3.71
| Professional | | $1.95 | $2.29 | $3.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.35 / $3.35 / $3.35
| Professional | | $3.35 | $3.35 | $3.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.29 / $2.75 / $3.44
| Professional | | $2.29 | $2.75 | $3.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.29 / $2.43 / $3.44
| Professional | | $2.29 | $2.43 | $3.44 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.44 / $2.31 / $4.88
| Professional | | $1.44 | $2.31 | $4.88 |