- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $1,230.27 / $1,230.27
| Facility | | $288.40 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $707.95 / $707.95 / $707.95
| Facility | TC | $707.95 | $707.95 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $275.42 / $537.03
| Professional | | $190.55 | $275.42 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.88 / $42.66 / $87.10
| Professional | 26 | $33.88 | $42.66 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $213.80
| Professional | 50 | $213.80 | $213.80 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $177.83 / $229.09 / $446.68
| Professional | TC | $177.83 | $229.09 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $331.13 / $562.34
| Professional | | $234.42 | $331.13 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.11 / $44.67 / $83.18
| Professional | 26 | $33.11 | $44.67 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $194.98 / $288.40 / $478.63
| Professional | TC | $194.98 | $288.40 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $316.23 / $346.74
| Professional | | $218.78 | $316.23 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $40.74 / $41.69
| Professional | 26 | $38.90 | $40.74 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $245.47 / $257.04 / $302.00
| Professional | TC | $245.47 | $257.04 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $316.23 / $371.54
| Professional | | $288.40 | $316.23 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $40.74 / $44.67 / $51.29
| Professional | 26 | $40.74 | $44.67 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $251.19 / $275.42 / $316.23
| Professional | TC | $251.19 | $275.42 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $363.08 / $676.08
| Professional | | $234.42 | $363.08 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $32.36 / $44.67 / $107.15
| Professional | 26 | $32.36 | $44.67 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $194.98 / $309.03 / $371.54
| Professional | TC | $194.98 | $309.03 | $371.54 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $323.59 / $691.83
| Professional | | $234.42 | $323.59 | $691.83 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $32.36 / $44.67 / $95.50
| Professional | 26 | $32.36 | $44.67 | $95.50 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $199.53 / $275.42 / $602.56
| Professional | TC | $199.53 | $275.42 | $602.56 |