| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Professional | AA | $840.00 | $840.00 | $840.00 |
Providence
| Facility | QK | $203.50 | $203.50 | $203.50 |
Providence
| Facility | QX | $203.50 | $203.50 | $203.50 |
Providence
| Facility | QY | $203.50 | $203.50 | $203.50 |