| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Professional | AA | $873.54 | $873.54 | $873.54 |
Aetna
| Professional | QX | $282.37 | $385.43 | $658.98 |
Aetna
| Professional | QY | $303.13 | $328.05 | $328.05 |
United
| Professional | QY | $80.00 | $80.00 | $80.00 |