- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $954.99 / $954.99
| Facility | | $954.99 | $954.99 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $213.80 / $398.11
| Professional | | $169.82 | $213.80 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $36.31 / $46.77 / $87.10
| Professional | 26 | $36.31 | $46.77 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $134.90 / $169.82 / $316.23
| Professional | TC | $134.90 | $169.82 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $251.19 / $436.52
| Professional | | $181.97 | $251.19 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $34.67 / $45.71 / $83.18
| Professional | 26 | $34.67 | $45.71 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $138.04 / $199.53 / $389.05
| Professional | TC | $138.04 | $199.53 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $234.42 / $263.03
| Professional | | $181.97 | $234.42 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $41.69 / $43.65 / $44.67
| Professional | 26 | $41.69 | $43.65 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $181.97 / $190.55 / $223.87
| Professional | TC | $181.97 | $190.55 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $239.88 / $275.42
| Professional | | $218.78 | $239.88 | $275.42 |
- 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
- $177.83 / $194.98 / $229.09
| Professional | TC | $177.83 | $194.98 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $269.15 / $501.19
| Professional | | $173.78 | $269.15 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $34.67 / $45.71 / $104.71
| Professional | 26 | $34.67 | $45.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $138.04 / $213.80 / $269.15
| Professional | TC | $138.04 | $213.80 | $269.15 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $239.88 / $407.38
| Professional | | $177.83 | $239.88 | $407.38 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.11 / $44.67 / $93.33
| Professional | 26 | $33.11 | $44.67 | $93.33 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $144.54 / $199.53 / $309.03
| Professional | TC | $144.54 | $199.53 | $309.03 |