| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | $17.79 | $63.70 | $363.46 | |
Aetna
| Professional | $127.40 | $282.80 | $282.80 | |
Moda Health
| Facility | $141.84 | $141.84 | $141.84 |
Compounded drug, not otherwise classified
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | $17.79 | $63.70 | $363.46 | |
Aetna
| Professional | $127.40 | $282.80 | $282.80 | |
Moda Health
| Facility | $141.84 | $141.84 | $141.84 |