- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $2,884.03 / $2,884.03
| Facility | | $1,000.00 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $426.58 / $630.96
| Professional | | $371.54 | $426.58 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $125.89 / $141.25 / $309.03
| Professional | 26 | $125.89 | $141.25 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $239.88 / $275.42 / $446.68
| Professional | TC | $239.88 | $275.42 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $380.19 / $478.63
| Professional | | $346.74 | $380.19 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $125.89 / $151.36 / $234.42
| Professional | 26 | $125.89 | $151.36 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $223.87 / $229.09 / $457.09
| Professional | TC | $223.87 | $229.09 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $616.60 / $2,511.89
| Professional | | $501.19 | $616.60 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $169.82 / $177.83 / $190.55
| Professional | 26 | $169.82 | $177.83 | $190.55 |
- 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
- $426.58 / $467.74 / $575.44
| Professional | | $426.58 | $467.74 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $138.04 / $151.36 / $190.55
| Professional | 26 | $138.04 | $151.36 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $281.84 / $309.03 / $389.05
| Professional | TC | $281.84 | $309.03 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,096.48 / $1,096.48
| Facility | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $436.52 / $562.34
| Professional | | $389.05 | $436.52 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $123.03 / $177.83 / $181.97
| Professional | 26 | $123.03 | $177.83 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $257.04 / $263.03 / $380.19
| Professional | TC | $257.04 | $263.03 | $380.19 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $380.19 / $575.44
| Professional | | $70.79 | $380.19 | $575.44 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $109.65 / $165.96
| Professional | 26 | $20.89 | $109.65 | $165.96 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $51.29 / $269.15 / $407.38
| Professional | TC | $51.29 | $269.15 | $407.38 |