| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Molina
| Professional | $17.00 | $17.00 | $20.00 |
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| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Molina
| Professional | $17.00 | $17.00 | $20.00 |