| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Medica
| Facility | $38.08 | $38.08 | $38.08 | |
Sanford Health Plan
| Facility | $100.00 | $100.00 | $100.00 |
Pharmacy - Other Pharmacy
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Medica
| Facility | $38.08 | $38.08 | $38.08 | |
Sanford Health Plan
| Facility | $100.00 | $100.00 | $100.00 |