| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | QK | $707.95 | $707.95 | $1,778.28 |
Aetna
| Facility | QX | $575.44 | $776.25 | $4,677.35 |
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 |