- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $562.34 / $630.96
| Facility | | $128.82 | $562.34 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $323.59 / $323.59 / $323.59
| Facility | TC | $323.59 | $323.59 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $23.99 / $134.90 / $263.03
| Professional | | $23.99 | $134.90 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.95 / $26.92 / $89.13
| Professional | 26 | $19.95 | $26.92 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $89.13 / $114.82 / $213.80
| Professional | TC | $89.13 | $114.82 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $165.96 / $257.04
| Professional | | $117.49 | $165.96 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $25.70 / $47.86
| Professional | 26 | $20.89 | $25.70 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $141.25 / $213.80
| Professional | TC | $95.50 | $141.25 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $35.48 / $181.97 / $204.17
| Professional | | $35.48 | $181.97 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.18 / $29.51 / $30.20
| Professional | 26 | $28.18 | $29.51 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $144.54 / $151.36 / $165.96
| Professional | TC | $144.54 | $151.36 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $154.88 / $181.97
| Professional | | $141.25 | $154.88 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $24.55 / $28.84
| Professional | 26 | $22.91 | $24.55 | $28.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $120.23 / $131.83 / $151.36
| Professional | TC | $120.23 | $131.83 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $181.97 / $363.08
| Professional | | $114.82 | $181.97 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.42 / $33.11 / $100.00
| Professional | 26 | $20.42 | $33.11 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $138.04 / $309.03
| Professional | TC | $95.50 | $138.04 | $309.03 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $158.49 / $316.23
| Professional | | $117.49 | $158.49 | $316.23 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.05 / $25.70 / $53.70
| Professional | 26 | $19.05 | $25.70 | $53.70 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $100.00 / $131.83 / $263.03
| Professional | TC | $100.00 | $131.83 | $263.03 |