- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.99 / $5.66 / $7.26
| Facility | | $4.99 | $5.66 | $7.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.93 / $7.26 / $7.26
| Professional | | $3.93 | $7.26 | $7.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.15 / $10.76 / $12.63
| Professional | | $8.15 | $10.76 | $12.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.05 / $7.26 / $9.08
| Professional | | $6.05 | $7.26 | $9.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.54 / $7.26 / $9.76
| Professional | | $2.54 | $7.26 | $9.76 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.78 / $9.13 / $12.99
| Professional | | $6.78 | $9.13 | $12.99 |