| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | QK | $223.87 | $223.87 | $223.87 |
Aetna
| Facility | QX | $309.03 | $309.03 | $309.03 |
Martin's Point
| Facility | QK | $223.87 | $223.87 | $223.87 |
Martin's Point
| Facility | QX | $309.03 | $309.03 | $309.03 |