| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | QX | $409.92 | $804.10 | $893.20 |
Wellcare
| Facility | QK | $37.00 | $37.00 | $39.50 |
Wellcare
| Facility | QX | $37.00 | $37.00 | $39.50 |
Wellcare
| Facility | QY | $37.00 | $37.00 | $39.50 |