| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Professional | QZ | $1,621.81 | $2,041.74 | $2,041.74 |
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 |