| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | $50.00 | $50.00 | $50.00 | |
Aetna
| Professional | AA | $108.07 | $108.07 | $700.00 |
Providence
| Professional | QX | $145.00 | $194.25 | $202.50 |
Providence
| Professional | QY | $145.00 | $194.25 | $202.50 |