- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $165.96 / $269.15
| Professional | | $87.10 | $165.96 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $43.65 / $70.79 / $204.17
| Professional | 26 | $43.65 | $70.79 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $60.26 / $117.49 / $204.17
| Professional | TC | $60.26 | $117.49 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $147.91
| Professional | | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $39.81 / $39.81
| Professional | 26 | $39.81 | $39.81 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $107.15
| Professional | TC | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $199.53 / $295.12
| Professional | | $83.18 | $199.53 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $95.50 / $97.72
| Professional | 26 | $91.20 | $95.50 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $190.55 / $199.53 / $199.53
| Professional | TC | $190.55 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $151.36 / $223.87
| Professional | | $125.89 | $151.36 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $34.67 / $41.69 / $61.66
| Professional | 26 | $34.67 | $41.69 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $100.00 / $162.18
| Professional | TC | $91.20 | $100.00 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $114.82 / $190.55
| Professional | | $61.66 | $114.82 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.42 / $41.69 / $54.95
| Professional | 26 | $20.42 | $41.69 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $40.74 / $74.13 / $134.90
| Professional | TC | $40.74 | $74.13 | $134.90 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $251.19 / $426.58
| Professional | | $144.54 | $251.19 | $426.58 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $67.61 / $109.65
| Professional | 26 | $38.90 | $67.61 | $109.65 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $104.71 / $169.82 / $323.59
| Professional | TC | $104.71 | $169.82 | $323.59 |