- 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
- $537.03 / $1,412.54 / $3,162.28
| Professional | AA | $537.03 | $1,412.54 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- QZ
- Typical Low / Median / Typical High
- $346.74 / $891.25 / $1,584.89
| Professional | QZ | $346.74 | $891.25 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- AA
- Typical Low / Median / Typical High
- $239.88 / $776.25 / $1,230.27
| Professional | AA | $239.88 | $776.25 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- QZ
- Typical Low / Median / Typical High
- $141.25 / $501.19 / $1,000.00
| Professional | QZ | $141.25 | $501.19 | $1,000.00 |
- 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
- $512.86 / $1,584.89 / $3,388.44
| Professional | AA | $512.86 | $1,584.89 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- QZ
- Typical Low / Median / Typical High
- $338.84 / $660.69 / $1,584.89
| Professional | QZ | $338.84 | $660.69 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- AA
- Typical Low / Median / Typical High
- $79.43 / $398.11 / $562.34
| Professional | AA | $79.43 | $398.11 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- QZ
- Typical Low / Median / Typical High
- $79.43 / $87.10 / $467.74
| Professional | QZ | $79.43 | $87.10 | $467.74 |