- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $467.74 / $794.33
| Professional | | $338.84 | $467.74 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $128.82 / $251.19 / $562.34
| Professional | 26 | $128.82 | $251.19 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $213.80 / $371.54 / $549.54
| Professional | TC | $213.80 | $371.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $575.44 / $575.44
| Professional | | $575.44 | $575.44 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $177.83
| Professional | 26 | $177.83 | $177.83 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $398.11 / $398.11 / $398.11
| Professional | TC | $398.11 | $398.11 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $501.19 / $616.60
| Professional | | $218.78 | $501.19 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $162.18 / $169.82 / $245.47
| Professional | 26 | $162.18 | $169.82 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $338.84 / $354.81 / $371.54
| Professional | TC | $338.84 | $354.81 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $588.84 / $891.25
| Professional | | $501.19 | $588.84 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $154.88 / $181.97 / $269.15
| Professional | 26 | $154.88 | $181.97 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $346.74 / $380.19 / $616.60
| Professional | TC | $346.74 | $380.19 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $229.09 / $707.95
| Professional | | $144.54 | $229.09 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $74.13 / $87.10 / $239.88
| Professional | 26 | $74.13 | $87.10 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $72.44 / $141.25 / $467.74
| Professional | TC | $72.44 | $141.25 | $467.74 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $549.54 / $707.95
| Professional | | $251.19 | $549.54 | $707.95 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $138.04 / $190.55 / $251.19
| Professional | 26 | $138.04 | $190.55 | $251.19 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $104.71 / $331.13 / $489.78
| Professional | TC | $104.71 | $331.13 | $489.78 |