| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Molina
| Facility | $46.62 | $756.73 | $9,745.90 |
Pharmacy
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Molina
| Facility | $46.62 | $756.73 | $9,745.90 |