| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | $19.57 | $19.57 | $19.57 | |
Aetna
| Professional | $19.57 | $19.57 | $19.57 | |
CareFirst
| Professional | $24.24 | $24.24 | $24.24 | |
Cigna
| Professional | $17.32 | $17.32 | $17.32 |
Non-Standard Size Or Length (Special Coverage Instructions Apply. See Mcm: 2323)
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | $19.57 | $19.57 | $19.57 | |
Aetna
| Professional | $19.57 | $19.57 | $19.57 | |
CareFirst
| Professional | $24.24 | $24.24 | $24.24 | |
Cigna
| Professional | $17.32 | $17.32 | $17.32 |