- Facility/Professional
- Facility
- Modifier
- AA
- Typical Low / Median / Typical High
- $6,918.31 / $6,918.31 / $6,918.31
| Facility | AA | $6,918.31 | $6,918.31 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- AA
- Typical Low / Median / Typical High
- $588.84 / $954.99 / $1,621.81
| Professional | AA | $588.84 | $954.99 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- QZ
- Typical Low / Median / Typical High
- $363.08 / $588.84 / $891.25
| Professional | QZ | $363.08 | $588.84 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- AA
- Typical Low / Median / Typical High
- $524.81 / $707.95 / $912.01
| Professional | AA | $524.81 | $707.95 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- QZ
- Typical Low / Median / Typical High
- $141.25 / $457.09 / $954.99
| Professional | QZ | $141.25 | $457.09 | $954.99 |
- Facility/Professional
- Facility
- Modifier
- QK
- Typical Low / Median / Typical High
- $30.90 / $30.90 / $30.90
| Facility | QK | $30.90 | $30.90 | $30.90 |
- Facility/Professional
- Facility
- Modifier
- QX
- Typical Low / Median / Typical High
- $30.90 / $30.90 / $30.90
| Facility | QX | $30.90 | $30.90 | $30.90 |
- Facility/Professional
- Facility
- Modifier
- QY
- Typical Low / Median / Typical High
- $30.90 / $30.90 / $30.90
| Facility | QY | $30.90 | $30.90 | $30.90 |
- Facility/Professional
- Facility
- Modifier
- QK
- Typical Low / Median / Typical High
- $52.48 / $52.48 / $52.48
| Facility | QK | $52.48 | $52.48 | $52.48 |
- Facility/Professional
- Facility
- Modifier
- QX
- Typical Low / Median / Typical High
- $52.48 / $52.48 / $52.48
| Facility | QX | $52.48 | $52.48 | $52.48 |
- Facility/Professional
- Facility
- Modifier
- QY
- Typical Low / Median / Typical High
- $52.48 / $52.48 / $52.48
| Facility | QY | $52.48 | $52.48 | $52.48 |
- Facility/Professional
- Facility
- Modifier
- AA
- Typical Low / Median / Typical High
- $6,918.31 / $6,918.31 / $6,918.31
| Facility | AA | $6,918.31 | $6,918.31 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- AA
- Typical Low / Median / Typical High
- $588.84 / $954.99 / $1,621.81
| Professional | AA | $588.84 | $954.99 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- QZ
- Typical Low / Median / Typical High
- $371.54 / $660.69 / $1,258.93
| Professional | QZ | $371.54 | $660.69 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- AA
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $87.10
| Professional | AA | $87.10 | $87.10 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- QZ
- Typical Low / Median / Typical High
- $75.86 / $75.86 / $75.86
| Professional | QZ | $75.86 | $75.86 | $75.86 |