| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Medica
| Facility | $1.21 | $5.29 | $17.16 |
Pharmacy Extension of 025X-Self-Administrable Drugs
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Medica
| Facility | $1.21 | $5.29 | $17.16 |