| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | $900.00 | $900.00 | $900.00 | |
United
| Facility | $4,635.00 | $4,635.00 | $6,784.00 |
Pharmacy
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | $900.00 | $900.00 | $900.00 | |
United
| Facility | $4,635.00 | $4,635.00 | $6,784.00 |