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Washington rates for HCPCS J0120

Injection Tetracycline Up To 250 Mg (Special Coverage Instructions Apply. See Mcm: 2049)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$14.14 / $14.14 / $33.28
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$13.81 / $14.14 / $14.14
Asuris Northwest Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.65 / $1.65 / $100.00
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $50.00 / $50.00
Pacific Source
Facility/Professional
Facility
Modifier
Low / Median / High Price
$79,999.20 / $79,999.20 / $79,999.20