| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Medica
| Facility | $2.67 | $2.67 | $4.59 | |
Sanford Health Plan
| Facility | $100.00 | $100.00 | $100.00 |
Pharmacy Extension of 025X-Self-Administrable Drugs
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Medica
| Facility | $2.67 | $2.67 | $4.59 | |
Sanford Health Plan
| Facility | $100.00 | $100.00 | $100.00 |