- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $323.59 / $851.14
| Professional | | $251.19 | $323.59 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $91.20 / $234.42
| Professional | 26 | $53.70 | $91.20 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $181.97 / $234.42 / $363.08
| Professional | TC | $181.97 | $234.42 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $380.19 / $676.08
| Professional | | $263.03 | $380.19 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $79.43 / $144.54
| Professional | 26 | $53.70 | $79.43 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $204.17 / $288.40 / $524.81
| Professional | TC | $204.17 | $288.40 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $389.05 / $457.09
| Professional | | $295.12 | $389.05 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $114.82 / $120.23 / $123.03
| Professional | 26 | $114.82 | $120.23 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $275.42 / $288.40 / $346.74
| Professional | TC | $275.42 | $288.40 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $346.74 / $398.11
| Professional | | $316.23 | $346.74 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $64.57 / $74.13
| Professional | 26 | $58.88 | $64.57 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $257.04 / $281.84 / $323.59
| Professional | TC | $257.04 | $281.84 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $416.87 / $741.31
| Professional | | $257.04 | $416.87 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $87.10 / $154.88
| Professional | 26 | $52.48 | $87.10 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $204.17 / $323.59 / $588.84
| Professional | TC | $204.17 | $323.59 | $588.84 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $354.81 / $741.31
| Professional | | $263.03 | $354.81 | $741.31 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $48.98 / $67.61 / $138.04
| Professional | 26 | $48.98 | $67.61 | $138.04 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $199.53 / $288.40 / $602.56
| Professional | TC | $199.53 | $288.40 | $602.56 |