| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Professional | QZ | $218.78 | $562.34 | $977.24 |
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 |