| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Moda Health
| Facility | $53.40 | $53.40 | $53.40 |
Pharmacy - Drugs Incident to Other Diagnostic Services
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Moda Health
| Facility | $53.40 | $53.40 | $53.40 |