| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Medica
| Facility | $103.63 | $155.61 | $211.49 |
Pharmacy - Drugs Incident to Other Diagnostic Services
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Medica
| Facility | $103.63 | $155.61 | $211.49 |