| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Professional | AA | $234.42 | $489.78 | $489.78 |
Aetna
| Professional | QX | $269.15 | $389.05 | $537.03 |
Aetna
| Professional | QY | $269.15 | $269.15 | $389.05 |
Aetna
| Professional | QZ | $100.00 | $100.00 | $100.00 |
Ambetter
| Professional | AA | $79.43 | $79.43 | $79.43 |