| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | $99.71 | $129.10 | $642.60 | |
Aetna
| Facility | 54 | $67.98 | $88.03 | $141.22 |
CareSource
| Facility | $100.22 | $111.26 | $121.23 | |
Cigna
| Facility | $160.71 | $160.71 | $160.71 | |
Cigna
| Facility | 54 | $112.50 | $112.50 | $112.50 |