| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Pacific Source
| Facility | $95.50 | $117.49 | $123.03 |
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Pacific Source
| Facility | $95.50 | $117.49 | $123.03 |