| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Professional | AA | $907.20 | $1,157.09 | $1,820.00 |
Providence
| Facility | QK | $244.20 | $244.20 | $244.20 |
Providence
| Facility | QX | $244.20 | $244.20 | $244.20 |
Providence
| Facility | QY | $244.20 | $244.20 | $244.20 |