| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Professional | AA | $340.96 | $840.00 | $1,820.00 |
Providence
| Facility | QK | $162.80 | $162.80 | $162.80 |
Providence
| Facility | QX | $162.80 | $162.80 | $162.80 |
Providence
| Facility | QY | $162.80 | $162.80 | $162.80 |