| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | $15.00 | $15.00 | $15.00 | |
Aetna
| Professional | $15.00 | $15.00 | $15.00 | |
Cigna
| Professional | $1.68 | $1.68 | $1.68 | |
Molina
| Professional | $30.00 | $45.00 | $60.00 |
Topical Anesthetic For Dialysis Per Gram (Special Coverage Instructions Apply. See Mcm: 4270)
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | $15.00 | $15.00 | $15.00 | |
Aetna
| Professional | $15.00 | $15.00 | $15.00 | |
Cigna
| Professional | $1.68 | $1.68 | $1.68 | |
Molina
| Professional | $30.00 | $45.00 | $60.00 |