| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Moda Health
| Facility | $11.03 | $11.03 | $18.30 |
Pharmacy - Other Pharmacy
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Moda Health
| Facility | $11.03 | $11.03 | $18.30 |