- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $295.12 / $295.12 / $295.12
| Facility | TC | $295.12 | $295.12 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.18 / $43.65 / $120.23
| Professional | | $28.18 | $43.65 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.05 / $24.55 / $63.10
| Professional | 26 | $19.05 | $24.55 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $234.42 / $234.42 / $234.42
| Professional | 50 | $234.42 | $234.42 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $14.13 / $20.89 / $58.88
| Professional | TC | $14.13 | $20.89 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $69.18 / $134.90
| Professional | | $43.65 | $69.18 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.42 / $26.92 / $42.66
| Professional | 26 | $20.42 | $26.92 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $20.42 / $45.71 / $91.20
| Professional | TC | $20.42 | $45.71 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $36.31 / $95.50 / $102.33
| Professional | | $36.31 | $95.50 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $29.51 / $30.20 / $31.62
| Professional | 26 | $29.51 | $30.20 | $31.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $67.61 / $70.79 / $70.79
| Professional | TC | $67.61 | $70.79 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $47.86 / $56.23
| Professional | | $43.65 | $47.86 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.44 / $25.70 / $29.51
| Professional | 26 | $23.44 | $25.70 | $29.51 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $20.89 / $22.39 / $26.30
| Professional | TC | $20.89 | $22.39 | $26.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $85.11 / $158.49
| Professional | | $37.15 | $85.11 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.50 / $27.54 / $52.48
| Professional | 26 | $19.50 | $27.54 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $16.60 / $40.74 / $109.65
| Professional | TC | $16.60 | $40.74 | $109.65 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $34.67 / $57.54 / $93.33
| Professional | | $34.67 | $57.54 | $93.33 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.22 / $25.70 / $28.84
| Professional | 26 | $16.22 | $25.70 | $28.84 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.05 / $30.90 / $66.07
| Professional | TC | $19.05 | $30.90 | $66.07 |