- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $138.04 / $389.05
| Professional | | $109.65 | $138.04 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $66.07 / $131.83
| Professional | 26 | $57.54 | $66.07 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $52.48 / $64.57 / $154.88
| Professional | TC | $52.48 | $64.57 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $173.78 / $295.12
| Professional | | $120.23 | $173.78 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $60.26 / $74.13 / $128.82
| Professional | 26 | $60.26 | $74.13 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $57.54 / $91.20 / $194.98
| Professional | TC | $57.54 | $91.20 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $288.40 / $309.03
| Professional | | $199.53 | $288.40 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $77.62 / $81.28 / $83.18
| Professional | 26 | $77.62 | $81.28 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $213.80 / $223.87 / $223.87
| Professional | TC | $213.80 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $158.49 / $181.97
| Professional | | $144.54 | $158.49 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $74.13 / $85.11
| Professional | 26 | $67.61 | $74.13 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $75.86 / $83.18 / $97.72
| Professional | TC | $75.86 | $83.18 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $169.82 / $229.09
| Professional | | $109.65 | $169.82 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $77.62 / $97.72
| Professional | 26 | $52.48 | $77.62 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $56.23 / $83.18 / $151.36
| Professional | TC | $56.23 | $83.18 | $151.36 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $158.49 / $331.13
| Professional | | $109.65 | $158.49 | $331.13 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $72.44 / $151.36
| Professional | 26 | $52.48 | $72.44 | $151.36 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $57.54 / $83.18 / $199.53
| Professional | TC | $57.54 | $83.18 | $199.53 |