- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $89.13 / $147.91
| Professional | | $60.26 | $89.13 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.42 / $29.51 / $67.61
| Professional | 26 | $20.42 | $29.51 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $31.62 / $61.66 / $93.33
| Professional | TC | $31.62 | $61.66 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $95.50
| Professional | | $95.50 | $95.50 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $27.54 / $27.54 / $27.54
| Professional | 26 | $27.54 | $27.54 | $27.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $67.61 / $67.61 / $67.61
| Professional | TC | $67.61 | $67.61 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $93.33 / $138.04
| Professional | | $51.29 | $93.33 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $41.69 / $60.26
| Professional | 26 | $39.81 | $41.69 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $53.70 / $56.23 / $77.62
| Professional | TC | $53.70 | $56.23 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $97.72 / $147.91
| Professional | | $83.18 | $97.72 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $24.55 / $28.84 / $43.65
| Professional | 26 | $24.55 | $28.84 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $58.88 / $64.57 / $104.71
| Professional | TC | $58.88 | $64.57 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.88 / $38.90 / $104.71
| Professional | | $33.88 | $38.90 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.49 / $18.20 / $36.31
| Professional | 26 | $13.49 | $18.20 | $36.31 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $20.42 / $20.42 / $67.61
| Professional | TC | $20.42 | $20.42 | $67.61 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $97.72 / $141.25
| Professional | | $58.88 | $97.72 | $141.25 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.99 / $35.48 / $50.12
| Professional | 26 | $23.99 | $35.48 | $50.12 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.12 / $67.61 / $89.13
| Professional | TC | $25.12 | $67.61 | $89.13 |