- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $151.36 / $457.09
| Professional | | $102.33 | $151.36 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $35.48 / $109.65
| Professional | 26 | $22.91 | $35.48 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $72.44 / $93.33 / $186.21
| Professional | TC | $72.44 | $93.33 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $138.04 / $223.87
| Professional | | $97.72 | $138.04 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $24.55 / $30.20 / $53.70
| Professional | 26 | $24.55 | $30.20 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $72.44 / $102.33 / $169.82
| Professional | TC | $72.44 | $102.33 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $194.98 / $2,398.83
| Professional | | $125.89 | $194.98 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $40.74 / $42.66 / $44.67
| Professional | 26 | $40.74 | $42.66 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $141.25 / $147.91 / $147.91
| Professional | TC | $141.25 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $134.90 / $158.49
| Professional | | $123.03 | $134.90 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.18 / $30.20 / $35.48
| Professional | 26 | $28.18 | $30.20 | $35.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $104.71 / $120.23
| Professional | TC | $95.50 | $104.71 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $128.82 / $177.83
| Professional | | $75.86 | $128.82 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.44 / $33.11 / $64.57
| Professional | 26 | $23.44 | $33.11 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $72.44 / $97.72 / $147.91
| Professional | TC | $72.44 | $97.72 | $147.91 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $131.83 / $346.74
| Professional | | $95.50 | $131.83 | $346.74 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.39 / $30.90 / $53.70
| Professional | 26 | $22.39 | $30.90 | $53.70 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $72.44 / $100.00 / $186.21
| Professional | TC | $72.44 | $100.00 | $186.21 |