Insurance Carrier	Facility/Professional	Modifier	Low Price	Median Price	High Price
Aetna Facility/Professional Facility Modifier Low / Median / High Price $30.00 / $290.00 / $375.00	Facility		$30.00	$290.00	$375.00
Aetna Facility/Professional Professional Modifier QX Low / Median / High Price $229.73 / $658.60 / $1,260.51	Professional	QX	$229.73	$658.60	$1,260.51
Aetna Facility/Professional Professional Modifier QZ Low / Median / High Price $495.50 / $495.50 / $495.50	Professional	QZ	$495.50	$495.50	$495.50
Ambetter Facility/Professional Professional Modifier AA Low / Median / High Price $455.00 / $455.00 / $455.00	Professional	AA	$455.00	$455.00	$455.00
Ambetter Facility/Professional Professional Modifier QX Low / Median / High Price $64.51 / $126.16 / $510.00	Professional	QX	$64.51	$126.16	$510.00
Ambetter Facility/Professional Professional Modifier QY Low / Median / High Price $117.35 / $257.13 / $257.13	Professional	QY	$117.35	$257.13	$257.13
Ambetter Facility/Professional Professional Modifier QZ Low / Median / High Price $100.45 / $120.54 / $143.36	Professional	QZ	$100.45	$120.54	$143.36
CareSource Facility/Professional Facility Modifier Low / Median / High Price $101.55 / $189.44 / $391.65	Facility		$101.55	$189.44	$391.65
Kaiser Permanente Facility/Professional Professional Modifier Low / Median / High Price $190.00 / $421.60 / $658.00	Professional		$190.00	$421.60	$658.00
Kaiser Permanente Facility/Professional Professional Modifier QK Low / Median / High Price $122.89 / $122.89 / $164.50	Professional	QK	$122.89	$122.89	$164.50
Kaiser Permanente Facility/Professional Professional Modifier QX Low / Median / High Price $122.89 / $122.89 / $164.50	Professional	QX	$122.89	$122.89	$164.50
Kaiser Permanente Facility/Professional Professional Modifier QY Low / Median / High Price $122.89 / $122.89 / $164.50	Professional	QY	$122.89	$122.89	$164.50