| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | $30.20 | $30.20 | $30.20 | |
Aetna
| Professional | $30.20 | $30.20 | $1,513.56 | |
Molina
| Professional | $60.26 | $60.26 | $85.11 | |
Providence
| Facility | $30.20 | $30.20 | $107.15 | |
Providence
| Professional | $41.69 | $41.69 | $41.69 |