- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $141.25 / $288.40
| Professional | | $117.49 | $141.25 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $25.70 / $54.95
| Professional | 26 | $21.88 | $25.70 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $93.33 / $112.20 / $251.19
| Professional | TC | $93.33 | $112.20 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $173.78 / $323.59
| Professional | | $123.03 | $173.78 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $27.54 / $53.70
| Professional | 26 | $21.88 | $27.54 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $97.72 / $138.04 / $295.12
| Professional | TC | $97.72 | $138.04 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $213.80 / $234.42
| Professional | | $165.96 | $213.80 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.70 / $27.54 / $28.18
| Professional | 26 | $25.70 | $27.54 | $28.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $165.96 / $173.78 / $204.17
| Professional | TC | $165.96 | $173.78 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $165.96 / $190.55
| Professional | | $151.36 | $165.96 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.70 / $27.54 / $32.36
| Professional | 26 | $25.70 | $27.54 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $125.89 / $138.04 / $158.49
| Professional | TC | $125.89 | $138.04 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $181.97 / $218.78
| Professional | | $120.23 | $181.97 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.95 / $25.70 / $38.90
| Professional | 26 | $19.95 | $25.70 | $38.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $97.72 / $144.54 / $190.55
| Professional | TC | $97.72 | $144.54 | $190.55 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $169.82 / $346.74
| Professional | | $123.03 | $169.82 | $346.74 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.38 / $28.18 / $58.88
| Professional | 26 | $21.38 | $28.18 | $58.88 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $102.33 / $138.04 / $281.84
| Professional | TC | $102.33 | $138.04 | $281.84 |