| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Ambetter
| Facility | $112.35 | $112.35 | $112.35 |
Other Clinic
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Ambetter
| Facility | $112.35 | $112.35 | $112.35 |