| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Medical Mutual of Ohio
| Facility | $3.28 | $3.28 | $3.28 |
Pharmacy-Other Pharmacy
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Medical Mutual of Ohio
| Facility | $3.28 | $3.28 | $3.28 |