- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $794.33 / $851.14
| Facility | | $794.33 | $794.33 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $234.42 / $467.74
| Professional | | $169.82 | $234.42 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.90 / $38.90 / $95.50
| Professional | 26 | $30.90 | $38.90 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $147.91 / $194.98 / $389.05
| Professional | TC | $147.91 | $194.98 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $257.04 / $416.87
| Professional | | $186.21 | $257.04 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $31.62 / $38.90 / $72.44
| Professional | 26 | $31.62 | $38.90 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $151.36 / $213.80 / $346.74
| Professional | TC | $151.36 | $213.80 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $257.04 / $295.12
| Professional | | $53.70 | $257.04 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $43.65 / $45.71 / $46.77
| Professional | 26 | $43.65 | $45.71 | $46.77 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $199.53 / $208.93 / $251.19
| Professional | TC | $199.53 | $208.93 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $245.47 / $288.40
| Professional | | $223.87 | $245.47 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $35.48 / $38.90 / $44.67
| Professional | 26 | $35.48 | $38.90 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $190.55 / $208.93 / $239.88
| Professional | TC | $190.55 | $208.93 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $275.42 / $549.54
| Professional | | $147.91 | $275.42 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $31.62 / $48.98 / $100.00
| Professional | 26 | $31.62 | $48.98 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $151.36 / $229.09 / $288.40
| Professional | TC | $151.36 | $229.09 | $288.40 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $251.19 / $524.81
| Professional | | $186.21 | $251.19 | $524.81 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $29.51 / $39.81 / $81.28
| Professional | 26 | $29.51 | $39.81 | $81.28 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $158.49 / $208.93 / $436.52
| Professional | TC | $158.49 | $208.93 | $436.52 |