- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $134.90
| Facility | | $134.90 | $134.90 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $154.88 / $338.84
| Professional | | $120.23 | $154.88 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $26.30 / $66.07
| Professional | 26 | $20.89 | $26.30 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $50.12 / $50.12 / $50.12
| Professional | 50 | $50.12 | $50.12 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $100.00 / $120.23 / $204.17
| Professional | TC | $100.00 | $120.23 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $199.53 / $323.59
| Professional | | $141.25 | $199.53 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.38 / $26.92 / $51.29
| Professional | 26 | $21.38 | $26.92 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $117.49 / $165.96 / $275.42
| Professional | TC | $117.49 | $165.96 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $208.93 / $239.88
| Professional | | $30.90 | $208.93 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $24.55 / $25.70 / $26.30
| Professional | 26 | $24.55 | $25.70 | $26.30 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $169.82 / $177.83 / $208.93
| Professional | TC | $169.82 | $177.83 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $173.78 / $199.53
| Professional | | $158.49 | $173.78 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $24.55 / $26.92 / $30.90
| Professional | 26 | $24.55 | $26.92 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $131.83 / $144.54 / $169.82
| Professional | TC | $131.83 | $144.54 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $213.80 / $398.11
| Professional | | $138.04 | $213.80 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.42 / $26.92 / $87.10
| Professional | 26 | $20.42 | $26.92 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $109.65 / $181.97 / $234.42
| Professional | TC | $109.65 | $181.97 | $234.42 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $173.78 / $371.54
| Professional | | $128.82 | $173.78 | $371.54 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.42 / $26.92 / $57.54
| Professional | 26 | $20.42 | $26.92 | $57.54 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $107.15 / $147.91 / $309.03
| Professional | TC | $107.15 | $147.91 | $309.03 |