- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $380.19 / $501.19
| Professional | | $338.84 | $380.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $112.20 / $169.82
| Professional | 26 | $104.71 | $112.20 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $229.09 / $269.15 / $371.54
| Professional | TC | $229.09 | $269.15 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $354.81 / $457.09
| Professional | | $316.23 | $354.81 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $128.82 / $194.98
| Professional | 26 | $104.71 | $128.82 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $213.80 / $223.87 / $446.68
| Professional | TC | $213.80 | $223.87 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $588.84 / $616.60
| Professional | | $489.78 | $588.84 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $165.96 / $169.82 / $186.21
| Professional | 26 | $165.96 | $169.82 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $478.63 / $501.19 / $537.03
| Professional | TC | $478.63 | $501.19 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $436.52 / $537.03
| Professional | | $398.11 | $436.52 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $117.49 / $128.82 / $158.49
| Professional | 26 | $117.49 | $128.82 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $281.84 / $309.03 / $380.19
| Professional | TC | $281.84 | $309.03 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $398.11 / $537.03
| Professional | | $371.54 | $398.11 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $147.91 / $154.88
| Professional | 26 | $104.71 | $147.91 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $251.19 / $269.15 / $380.19
| Professional | TC | $251.19 | $269.15 | $380.19 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $354.81 / $537.03
| Professional | | $67.61 | $354.81 | $537.03 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.38 / $93.33 / $138.04
| Professional | 26 | $17.38 | $93.33 | $138.04 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $50.12 / $263.03 / $398.11
| Professional | TC | $50.12 | $263.03 | $398.11 |