| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Moda Health
| Facility | $42.16 | $42.16 | $42.16 |
Pharmacy Extension of 025X-Drugs Requiring Detailed Coding
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Moda Health
| Facility | $42.16 | $42.16 | $42.16 |