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Wisconsin 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
$13.31 / $13.31 / $29.68
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$13.31 / $13.31 / $16.64
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.42 / $34.11 / $34.11
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$13.30 / $24.33 / $34.47
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$10.13 / $10.43 / $12.66
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$13.31 / $13.31 / $13.31
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$13.31 / $13.31 / $13.31
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $55.00 / $85.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$13.31 / $13.31 / $13.31