- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $218.78 / $229.09
| Professional | | $104.71 | $218.78 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $67.61 / $218.78
| Professional | 26 | $38.90 | $67.61 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $72.44 / $147.91 / $162.18
| Professional | TC | $72.44 | $147.91 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $199.53
| Professional | | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $51.29 / $51.29 / $51.29
| Professional | 26 | $51.29 | $51.29 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $151.36 / $151.36 / $151.36
| Professional | TC | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $162.18 / $269.15
| Professional | | $91.20 | $162.18 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $100.00 / $104.71 / $107.15
| Professional | 26 | $100.00 | $104.71 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $154.88 / $162.18 / $162.18
| Professional | TC | $154.88 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $208.93 / $316.23
| Professional | | $177.83 | $208.93 | $316.23 |
- 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
- $131.83 / $144.54 / $234.42
| Professional | TC | $131.83 | $144.54 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $83.18 / $223.87
| Professional | | $70.79 | $83.18 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $45.71 / $67.61
| Professional | 26 | $25.12 | $45.71 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.90 / $46.77 / $154.88
| Professional | TC | $38.90 | $46.77 | $154.88 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $234.42 / $371.54
| Professional | | $169.82 | $234.42 | $371.54 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $47.86 / $64.57 / $120.23
| Professional | 26 | $47.86 | $64.57 | $120.23 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $169.82 / $257.04
| Professional | TC | $95.50 | $169.82 | $257.04 |