- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $141.25 / $158.49
| Professional | | $93.33 | $141.25 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.99 / $60.26 / $177.83
| Professional | 26 | $23.99 | $60.26 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $58.88 / $100.00 / $123.03
| Professional | TC | $58.88 | $100.00 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $114.82 / $114.82
| Professional | | $114.82 | $114.82 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.99 / $23.99 / $23.99
| Professional | 26 | $23.99 | $23.99 | $23.99 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $91.20
| Professional | TC | $91.20 | $91.20 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $128.82 / $194.98
| Professional | | $43.65 | $128.82 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $32.36 / $33.88 / $47.86
| Professional | 26 | $32.36 | $33.88 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $95.50 / $147.91
| Professional | TC | $91.20 | $95.50 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $117.49 / $177.83
| Professional | | $100.00 | $117.49 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $24.55 / $37.15
| Professional | 26 | $20.89 | $24.55 | $37.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $79.43 / $85.11 / $138.04
| Professional | TC | $79.43 | $85.11 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $53.70 / $165.96
| Professional | | $52.48 | $53.70 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.18 / $14.45 / $36.31
| Professional | 26 | $13.18 | $14.45 | $36.31 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.90 / $39.81 / $128.82
| Professional | TC | $38.90 | $39.81 | $128.82 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $134.90 / $186.21
| Professional | | $66.07 | $134.90 | $186.21 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.38 / $30.20 / $42.66
| Professional | 26 | $21.38 | $30.20 | $42.66 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $35.48 / $107.15 / $144.54
| Professional | TC | $35.48 | $107.15 | $144.54 |