| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | $173.78 | $173.78 | $173.78 | |
Aetna
| Professional | $128.82 | $173.78 | $223.87 | |
Health Alliance Plan
| Facility | $173.78 | $173.78 | $173.78 | |
Health Alliance Plan
| Professional | $128.82 | $173.78 | $223.87 |