- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $1,584.89 / $2,818.38
| Facility | | $645.65 | $1,584.89 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $281.84 / $870.96
| Professional | | $181.97 | $281.84 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $79.43 / $218.78
| Professional | 26 | $64.57 | $79.43 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $128.82 / $181.97 / $354.81
| Professional | TC | $128.82 | $181.97 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $309.03 / $446.68
| Professional | | $194.98 | $309.03 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $85.11 / $154.88
| Professional | 26 | $64.57 | $85.11 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $125.89 / $199.53 / $288.40
| Professional | TC | $125.89 | $199.53 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $371.54 / $2,570.40
| Professional | | $251.19 | $371.54 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $117.49 / $123.03 / $125.89
| Professional | 26 | $117.49 | $123.03 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $239.88 / $251.19 / $251.19
| Professional | TC | $239.88 | $251.19 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $257.04 / $302.00
| Professional | | $239.88 | $257.04 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $75.86 / $83.18 / $97.72
| Professional | 26 | $75.86 | $83.18 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $162.18 / $173.78 / $204.17
| Professional | TC | $162.18 | $173.78 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $257.04 / $363.08
| Professional | | $158.49 | $257.04 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $87.10 / $107.15
| Professional | 26 | $64.57 | $87.10 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $125.89 / $173.78 / $269.15
| Professional | TC | $125.89 | $173.78 | $269.15 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $269.15 / $630.96
| Professional | | $194.98 | $269.15 | $630.96 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $89.13 / $154.88
| Professional | 26 | $54.95 | $89.13 | $154.88 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $131.83 / $194.98 / $316.23
| Professional | TC | $131.83 | $194.98 | $316.23 |