| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Medica
| Facility | $1.29 | $51.29 | $1,096.48 |
Pharmacy
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Medica
| Facility | $1.29 | $51.29 | $1,096.48 |