| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Medica
| Facility | $2.69 | $16.98 | $190.55 | |
Molina
| Facility | $12.30 | $199.53 | $2,818.38 |
Pharmacy
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Medica
| Facility | $2.69 | $16.98 | $190.55 | |
Molina
| Facility | $12.30 | $199.53 | $2,818.38 |