| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | $47.06 | $47.06 | $47.06 | |
Aetna
| Professional | $47.06 | $47.06 | $62.13 | |
Health Alliance Plan
| Facility | $47.06 | $47.06 | $47.06 | |
Health Alliance Plan
| Professional | $47.06 | $47.06 | $47.06 |