| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | AA | $5,888.44 | $5,888.44 | $5,888.44 |
Lucent Health
| Facility | QK | $52.48 | $52.48 | $52.48 |
Lucent Health
| Facility | QX | $52.48 | $52.48 | $52.48 |
Moda Health
| Facility | AA | $5,888.44 | $5,888.44 | $5,888.44 |
Providence
| Facility | QK | $30.90 | $30.90 | $30.90 |
Providence
| Facility | QX | $30.90 | $30.90 | $30.90 |