| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | QZ | $758.58 | $758.58 | $758.58 |
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 |