| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Medica
| Facility | $256.64 | $256.64 | $256.64 | |
Medica
| Professional | $802.69 | $802.69 | $802.69 | |
Midlands
| Facility | $313.70 | $313.70 | $313.70 | |
Midlands
| Professional | $313.70 | $313.70 | $313.70 |