| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Medica
| Facility | $56.78 | $56.78 | $56.78 |
Pharmacy Extension of 025X-Self-Administrable Drugs
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Medica
| Facility | $56.78 | $56.78 | $56.78 |