| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Molina
| Facility | $2.45 | $354.81 | $3,981.07 |
Pharmacy
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Molina
| Facility | $2.45 | $354.81 | $3,981.07 |