- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $169.82 / $398.11
| Professional | | $97.72 | $169.82 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $141.25 / $416.87
| Professional | 26 | $57.54 | $141.25 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.90 / $52.48 / $67.61
| Professional | TC | $30.90 | $52.48 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $131.83
| Professional | | $131.83 | $131.83 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $75.86 / $75.86 / $75.86
| Professional | 26 | $75.86 | $75.86 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $56.23 / $56.23 / $56.23
| Professional | TC | $56.23 | $56.23 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $141.25 / $173.78
| Professional | | $114.82 | $141.25 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $85.11 / $89.13 / $125.89
| Professional | 26 | $85.11 | $89.13 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $46.77 / $48.98 / $50.12
| Professional | TC | $46.77 | $48.98 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $134.90 / $204.17
| Professional | | $114.82 | $134.90 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $66.07 / $77.62 / $117.49
| Professional | 26 | $66.07 | $77.62 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $48.98 / $53.70 / $87.10
| Professional | TC | $48.98 | $53.70 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $54.95 / $162.18
| Professional | | $51.29 | $54.95 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $37.15 / $46.77 / $102.33
| Professional | 26 | $37.15 | $46.77 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $12.88 / $17.78 / $60.26
| Professional | TC | $12.88 | $17.78 | $60.26 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $141.25 / $169.82
| Professional | | $95.50 | $141.25 | $169.82 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $87.10 / $114.82
| Professional | 26 | $67.61 | $87.10 | $114.82 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $22.39 / $53.70 / $67.61
| Professional | TC | $22.39 | $53.70 | $67.61 |