| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | $13.81 | $13.81 | $13.81 | |
Aetna
| Professional | $13.81 | $13.81 | $13.81 |
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 | $13.81 | $13.81 | $13.81 | |
Aetna
| Professional | $13.81 | $13.81 | $13.81 |