| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | $2,750.00 | $2,750.00 | $2,750.00 | |
Blue Shield
| Facility | $23.40 | $38.79 | $45.70 | |
Kaiser Permanente
| Facility | $118.50 | $195.00 | $315.00 |
Pharmacy-Nongeneric Drugs
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | $2,750.00 | $2,750.00 | $2,750.00 | |
Blue Shield
| Facility | $23.40 | $38.79 | $45.70 | |
Kaiser Permanente
| Facility | $118.50 | $195.00 | $315.00 |