- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $138.04 / $309.03
| Professional | | $81.28 | $138.04 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.20 / $28.84 / $57.54
| Professional | 26 | $18.20 | $28.84 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $114.82 / $194.98
| Professional | TC | $95.50 | $114.82 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $173.78 / $302.00
| Professional | | $123.03 | $173.78 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.38 / $25.70 / $51.29
| Professional | 26 | $17.38 | $25.70 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $97.72 / $138.04 / $281.84
| Professional | TC | $97.72 | $138.04 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $181.97 / $204.17
| Professional | | $141.25 | $181.97 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.99 / $25.12 / $25.70
| Professional | 26 | $23.99 | $25.12 | $25.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $141.25 / $147.91 / $173.78
| Professional | TC | $141.25 | $147.91 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $162.18 / $186.21
| Professional | | $147.91 | $162.18 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $26.92 / $31.62
| Professional | 26 | $25.12 | $26.92 | $31.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $123.03 / $134.90 / $154.88
| Professional | TC | $123.03 | $134.90 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $165.96 / $213.80
| Professional | | $97.72 | $165.96 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.50 / $27.54 / $87.10
| Professional | 26 | $19.50 | $27.54 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $97.72 / $147.91 / $194.98
| Professional | TC | $97.72 | $147.91 | $194.98 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $165.96 / $346.74
| Professional | | $123.03 | $165.96 | $346.74 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.38 / $24.55 / $57.54
| Professional | 26 | $17.38 | $24.55 | $57.54 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $102.33 / $138.04 / $288.40
| Professional | TC | $102.33 | $138.04 | $288.40 |