| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | $416.87 | $416.87 | $549.54 | |
BCBS
| Facility | $1,905.46 | $2,137.96 | $4,073.80 |
Pharmacy-Extension of 025X and 063X - Reserved (Use 0250 for general c
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | $416.87 | $416.87 | $549.54 | |
BCBS
| Facility | $1,905.46 | $2,137.96 | $4,073.80 |
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