| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | AA | $467.74 | $467.74 | $467.74 |
Aetna
| Facility | QX | $389.05 | $851.14 | $1,318.26 |
Cigna
| Facility | QK | $30.90 | $30.90 | $30.90 |
Cigna
| Facility | QX | $30.90 | $30.90 | $30.90 |
Cigna
| Facility | QY | $30.90 | $30.90 | $30.90 |