| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | QK | $856.95 | $856.95 | $991.17 |
Aetna
| Facility | QX | $1,863.14 | $1,863.14 | $4,319.85 |
Martin's Point
| Facility | QK | $856.95 | $856.95 | $991.17 |
Martin's Point
| Facility | QX | $1,863.14 | $1,863.14 | $4,319.85 |