| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Professional | AA | $234.42 | $234.42 | $323.59 |
Aetna
| Professional | QX | $269.15 | $269.15 | $269.15 |
Aetna
| Professional | QY | $162.18 | $181.97 | $208.93 |
Ambetter
| Professional | AA | $123.03 | $123.03 | $123.03 |