| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Molina
| Facility | $4,168.69 | $4,168.69 | $4,168.69 |
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Molina
| Facility | $4,168.69 | $4,168.69 | $4,168.69 |