- 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
- $134.90 / $199.53 / $316.23
| Professional | | $134.90 | $199.53 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.02 / $44.67 / $114.82
| Professional | 26 | $38.02 | $44.67 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $87.10 / $158.49 / $239.88
| Professional | TC | $87.10 | $158.49 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $154.88 / $223.87
| Professional | | $114.82 | $154.88 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $47.86 / $72.44
| Professional | 26 | $38.90 | $47.86 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $75.86 / $104.71 / $177.83
| Professional | TC | $75.86 | $104.71 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $380.19 / $398.11
| Professional | | $295.12 | $380.19 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $147.91 / $154.88 / $165.96
| Professional | 26 | $147.91 | $154.88 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $295.12 / $309.03 / $338.84
| Professional | TC | $295.12 | $309.03 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $204.17 / $257.04
| Professional | | $190.55 | $204.17 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $43.65 / $47.86 / $60.26
| Professional | 26 | $43.65 | $47.86 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $144.54 / $158.49 / $194.98
| Professional | TC | $144.54 | $158.49 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $245.47 / $275.42
| Professional | | $181.97 | $245.47 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $57.54 / $60.26
| Professional | 26 | $38.90 | $57.54 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $144.54 / $186.21 / $213.80
| Professional | TC | $144.54 | $186.21 | $213.80 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $29.51 / $208.93 / $331.13
| Professional | | $29.51 | $208.93 | $331.13 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $6.76 / $47.86 / $144.54
| Professional | 26 | $6.76 | $47.86 | $144.54 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $22.91 / $162.18 / $371.54
| Professional | TC | $22.91 | $162.18 | $371.54 |