| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | QX | $616.60 | $616.60 | $977.24 |
Wellcare
| Facility | QK | $52.48 | $52.48 | $52.48 |
Wellcare
| Facility | QX | $52.48 | $52.48 | $52.48 |
Wellcare
| Facility | QY | $52.48 | $52.48 | $52.48 |