| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Moda Health
| Facility | $33.86 | $33.86 | $33.86 |
Pharmacy-Nongeneric Drugs
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Moda Health
| Facility | $33.86 | $33.86 | $33.86 |