| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | $199.53 | $199.53 | $199.53 | |
BCBS
| Facility | $0.06 | $0.16 | $2,691.53 |
Pharmacy Extension of 025X-Self-Administrable Drugs
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | $199.53 | $199.53 | $199.53 | |
BCBS
| Facility | $0.06 | $0.16 | $2,691.53 |
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