- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $154.88 / $234.42
| Professional | | $109.65 | $154.88 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $37.15 / $45.71 / $107.15
| Professional | 26 | $37.15 | $45.71 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $56.23 / $95.50 / $144.54
| Professional | TC | $56.23 | $95.50 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $162.18 / $213.80
| Professional | | $114.82 | $162.18 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $53.70 / $83.18
| Professional | 26 | $38.90 | $53.70 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $77.62 / $104.71 / $162.18
| Professional | TC | $77.62 | $104.71 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $186.21 / $213.80
| Professional | | $138.04 | $186.21 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $56.23 / $58.88
| Professional | 26 | $54.95 | $56.23 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $144.54 / $151.36 / $151.36
| Professional | TC | $144.54 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $218.78 / $251.19
| Professional | | $199.53 | $218.78 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $47.86 / $52.48 / $61.66
| Professional | 26 | $47.86 | $52.48 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $151.36 / $165.96 / $190.55
| Professional | TC | $151.36 | $165.96 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $162.18 / $275.42
| Professional | | $104.71 | $162.18 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $52.48 / $100.00
| Professional | 26 | $39.81 | $52.48 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $61.66 / $117.49 / $173.78
| Professional | TC | $61.66 | $117.49 | $173.78 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $158.49 / $177.83
| Professional | | $100.00 | $158.49 | $177.83 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.90 / $47.86 / $54.95
| Professional | 26 | $30.90 | $47.86 | $54.95 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $67.61 / $112.20 / $120.23
| Professional | TC | $67.61 | $112.20 | $120.23 |