| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Lucent Health
| Facility | QK | $37.00 | $37.00 | $39.50 |
Lucent Health
| Facility | QX | $37.00 | $37.00 | $39.50 |
Lucent Health
| Facility | QY | $37.00 | $37.00 | $39.50 |
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 |