| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Medica
| Facility | $346.42 | $346.42 | $346.42 | |
Molina
| Facility | $3,000.00 | $3,000.00 | $3,000.00 |
Pharmacy - Non-Generic Drugs
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Medica
| Facility | $346.42 | $346.42 | $346.42 | |
Molina
| Facility | $3,000.00 | $3,000.00 | $3,000.00 |