| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Professional | AA | $732.89 | $1,427.70 | $2,643.90 |
Aetna
| Professional | QX | $380.72 | $705.04 | $904.21 |
Aetna
| Professional | QY | $523.49 | $523.49 | $523.49 |
United
| Professional | QY | $80.00 | $80.00 | $80.00 |