| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | QX | $90.96 | $90.96 | $594.25 |
Aetna
| Facility | QZ | $2,211.60 | $2,211.60 | $2,211.60 |
Martin's Point
| Facility | QX | $90.96 | $90.96 | $594.25 |
Martin's Point
| Facility | QZ | $2,211.60 | $2,211.60 | $2,211.60 |