- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $147.91 / $251.19
| Professional | | $89.13 | $147.91 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $42.66 / $58.88 / $181.97
| Professional | 26 | $42.66 | $58.88 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $630.96
| Professional | 52 | $120.23 | $120.23 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $46.77 / $95.50 / $199.53
| Professional | TC | $46.77 | $95.50 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $151.36 / $288.40
| Professional | | $109.65 | $151.36 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $46.77 / $64.57 / $102.33
| Professional | 26 | $46.77 | $64.57 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $63.10 / $87.10 / $181.97
| Professional | TC | $63.10 | $87.10 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $263.03 / $316.23
| Professional | | $131.83 | $263.03 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $102.33 / $109.65 / $114.82
| Professional | 26 | $102.33 | $109.65 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $194.98 / $204.17 / $204.17
| Professional | TC | $194.98 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $134.90 / $169.82
| Professional | | $123.03 | $134.90 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $50.12 / $54.95 / $69.18
| Professional | 26 | $50.12 | $54.95 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $72.44 / $79.43 / $100.00
| Professional | TC | $72.44 | $79.43 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $125.89 / $269.15
| Professional | | $91.20 | $125.89 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $41.69 / $53.70 / $100.00
| Professional | 26 | $41.69 | $53.70 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $50.12 / $74.13 / $169.82
| Professional | TC | $50.12 | $74.13 | $169.82 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $144.54 / $234.42
| Professional | | $87.10 | $144.54 | $234.42 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $63.10 / $72.44
| Professional | 26 | $39.81 | $63.10 | $72.44 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $46.77 / $79.43 / $151.36
| Professional | TC | $46.77 | $79.43 | $151.36 |