| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Professional | QZ | $51.29 | $1,047.13 | $1,778.28 |
Lucent Health
| Facility | QK | $52.48 | $52.48 | $52.48 |
Lucent Health
| Facility | QX | $52.48 | $52.48 | $52.48 |
Lucent Health
| Facility | QY | $52.48 | $52.48 | $52.48 |