| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | $188.88 | $188.88 | $188.88 | |
Aetna
| Facility | 54 | $142.72 | $142.72 | $142.72 |
Martin's Point
| Facility | $188.88 | $188.88 | $207.81 | |
Martin's Point
| Facility | 54 | $142.72 | $142.72 | $142.72 |