- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.68 / $258.08 / $258.08
| Facility | | $31.68 | $258.08 | $258.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.22 / $0.22 / $0.22
| Professional | | $0.22 | $0.22 | $0.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $85.00 / $85.00 / $85.00
| Facility | | $85.00 | $85.00 | $85.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.22 / $0.22 / $0.26
| Professional | | $0.22 | $0.22 | $0.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.32 / $0.34 / $0.34
| Professional | | $0.32 | $0.34 | $0.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.24 / $0.26 / $0.30
| Professional | | $0.24 | $0.26 | $0.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.14 / $0.26 / $0.33
| Professional | | $0.14 | $0.26 | $0.33 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.21 / $0.26 / $0.34
| Professional | | $0.21 | $0.26 | $0.34 |