- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $169.82 / $194.98
| Professional | | $93.33 | $169.82 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $75.86 / $134.90
| Professional | 26 | $58.88 | $75.86 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $58.88 / $107.15 / $120.23
| Professional | TC | $58.88 | $107.15 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $154.88 / $154.88
| Professional | | $154.88 | $154.88 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $52.48 / $52.48
| Professional | 26 | $52.48 | $52.48 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $102.33
| Professional | TC | $102.33 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $194.98 / $331.13
| Professional | | $114.82 | $194.98 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $70.79 / $74.13 / $128.82
| Professional | 26 | $70.79 | $74.13 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $114.82 / $120.23 / $204.17
| Professional | TC | $114.82 | $120.23 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $162.18 / $245.47
| Professional | | $138.04 | $162.18 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $45.71 / $53.70 / $81.28
| Professional | 26 | $45.71 | $53.70 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $93.33 / $100.00 / $162.18
| Professional | TC | $93.33 | $100.00 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $93.33 / $213.80
| Professional | | $69.18 | $93.33 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $26.92 / $38.90 / $72.44
| Professional | 26 | $26.92 | $38.90 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $42.66 / $53.70 / $141.25
| Professional | TC | $42.66 | $53.70 | $141.25 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $190.55 / $309.03
| Professional | | $158.49 | $190.55 | $309.03 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $64.57 / $109.65
| Professional | 26 | $53.70 | $64.57 | $109.65 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $97.72 / $125.89 / $199.53
| Professional | TC | $97.72 | $125.89 | $199.53 |