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Montana rates for HCPCS J0295

Injection, ampicillin sodium/sulbactam sodium, per 1.5 g

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$46.91 / $80.28 / $244.72
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.40 / $1.80 / $6.92
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$8.64 / $77,999.99 / $94,999.99
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.79 / $1.79 / $8.14
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.39 / $1.39 / $1.79
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.79 / $1.79 / $8.14
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.39 / $1.51 / $2.42
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.39 / $1.39 / $1.39