| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Professional | AA | $3,500.00 | $3,500.00 | $3,500.00 |
Providence
| Facility | QK | $651.20 | $651.20 | $651.20 |
Providence
| Facility | QX | $651.20 | $651.20 | $651.20 |
Providence
| Facility | QY | $651.20 | $651.20 | $651.20 |