| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | $13.31 | $13.31 | $29.95 | |
Aetna
| Professional | $13.31 | $16.64 | $16.64 | |
Cigna
| Professional | $10.13 | $10.13 | $12.66 | |
Medica
| Facility | $13.31 | $13.31 | $39.93 |
Injection Tetracycline Up To 250 Mg (Special Coverage Instructions Apply. See Mcm: 2049)
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | $13.31 | $13.31 | $29.95 | |
Aetna
| Professional | $13.31 | $16.64 | $16.64 | |
Cigna
| Professional | $10.13 | $10.13 | $12.66 | |
Medica
| Facility | $13.31 | $13.31 | $39.93 |