| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Molina
| Facility | $53.70 | $660.69 | $7,585.78 |
Pharmacy
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Molina
| Facility | $53.70 | $660.69 | $7,585.78 |