| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | $50.00 | $50.00 | $50.00 | |
Aetna
| Professional | AA | $56.55 | $56.55 | $1,417.42 |
Aetna
| Professional | QK | $110.83 | $149.13 | $810.04 |
Aetna
| Professional | QX | $110.83 | $110.83 | $810.04 |