| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Medica
| Facility | $190.55 | $190.55 | $190.55 | |
Oscar Health
| Facility | $1,148.15 | $1,348.96 | $1,348.96 |
Pharmacy-Nongeneric Drugs
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Medica
| Facility | $190.55 | $190.55 | $190.55 | |
Oscar Health
| Facility | $1,148.15 | $1,348.96 | $1,348.96 |